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The  National  Center  on 
Addiction  and  Substance  Abuse 
at  Columbia  University 


^COLUMBIA 


633  Third  Avenue 

New  York,  NY  10017^706 

phone  212  841  5200 
fax  212  956  8020 
www.casacolumbia.org 

Hoard  qf  Directors 

Jeffrey  B.  Lane 
Chairman 

Joseph  A.  CaJifano,  Jr. 

Founder  and  Chair  Emeritus 

William  H.  Foster,  Ph.D. 

President  and  CEO 

Lee  C.  Bollinger 

Ursula  VI.  Hums 

Columba  Bush 

Kenneth  I.  Chenault 

Peter  R.  Dolan 

Victor  F.  Gan/.i 

Melioda  B.  Hilriebrand 

Ralph  Izzo,  Ph.D. 

Gene  F.  Jankowski 

David  A.  Kessler,  M.D. 

Jeffrey  B.  Kindler 

.Alan  I.  Leshner,  Ph.D. 

Rev.  Edward  A.  Malloy,  CSC 

Doug  Morris 

Bruce  F,.  Mosler 

Manuel  T.  Pacheco,  Ph.D. 

Joseph  J.  Plumeri 

Jim  Bamstad 

Shari  E.  Redstone 

F.  John  Rosenwald,  Jr. 

Michael  I.  Roth 

Mara  Burros  Sandler 

Michael  P.  Schulhof 

Louis  W.  Sullivan,  M.D. 

John  J.  Sweeney 

Clyde  C.  Higgle 


Directors  Emeritus 

James  E.  Burke  (1992-1997) 
Jamie  Lcc  Curtis  (2001-2009) 
Jamie  Dhnon  (1995-2009) 
Mary  Fislier  (1996  2005) 
Betty  Ford  (1992-1998) 
Douglas  A.  Fraser  (1992-2003) 
Barbara  C.  Jordan  (1992-1996) 
Leo  Kehnenson  (1998  2006) 
Donald  R.  Keough  (1992  2010) 
LaSalle  Lefiall  (1992-2001) 
Nancy  Reagan  (1995-2000) 
Linda  J.  Rice  (1992-1996) 
George  Bupp  (1993-2002) 
Michael  I.  Sovern  (1992-1993) 
Frank  G.  Wells  (1992-1994) 
Michael  A.  Wiener  (1997-2009) 


Addiction  Medicine: 

Closing  the  Gap  between  Science  and  Practice 


June  2012 


Funded  by: 

The  Annenberg  Foundation 

The  Diana,  Princess  of  Wales  Memorial  Fund  and  The  Franklin 

The  New  York  Community  Trust 

Adrian  and  Jessie  Archbold  Charitable  Trust 


Board  of  Directors 


Lee  C.  Bollinger  Rev.  Edward  A.  Malloy,  CSC 

President,  Columbia  University  President  Emeritus,  University  of  Notre  Dame 

Ursula  M.  Burns  Doug  Morris 

Chairman  and  CEO,  Xerox  Corporation  CEO,  Sony  Music  Entertainment 


Columba  Bush 

Former  First  Lady  of  Florida 

Joseph  A.  Califano,  Jr. 

Founder  and  Chairman  Emeritus,  CAS  A  Columbia 

Kenneth  I.  Chenault 

Chairman  and  CEO, 
American  Express  Company 

Peter  R.  Dolan 

Chairman,  ChildObesityl80 

William  H.  Foster,  Ph.D. 

President  and  CEO,  CASA  Columbia 

Victor  F.  Ganzi 

Chairman  of  the  Board  PGA  Tour 
Melinda  B.  Hildebrand 
Ralph  Izzo,  Ph.D. 

Chairman  of  the  Board,  CEO  and  President, 
Public  Service  Enterprise  Group,  Inc.  (PSEG) 

Gene  F.  Jankowski 

President,  CBS  Broadcasting,  Retired 

David  A.  Kessler,  M.D. 
Jeffrey  B.  Kindler 

Jeffrey  B.  Lane 

Chairman,  CASA  Columbia 

Alan  I.  Leshner,  Ph.D. 

CEO,  Executive  Publisher,  Science,  American 
Association  for  the  Advancement  of  Science 

Directors  Emeritus 
James  E.  Burke  (1992-1997) 
Jamie  Lee  Curtis  (2001-2009) 
Jamie  Dimon  (1995-2009) 
Mary  Fisher  (1996-2005) 
Betty  Ford  (1992-1998) 
Douglas  A.  Fraser  (1992-2003) 
Barbara  C.  Jordan  (1992-1996) 
Leo- Arthur  Kelmenson  (1998-2006) 


Bruce  E.  Mosler 

Chairman,  Global  Brokerage, 
Cushman  &  Wakefield,  Inc. 

Manuel  T.  Pacheco,  Ph.D. 

President  Emeritus,  University  of  Arizona  and 
University  of  Missouri  System 

Joseph  J.  Plumeri 

Chairman  and  CEO, 
Willis  Group  Holdings  PLC 

Jim  Ramstad 

Former  Member  of  Congress  (MN-3) 

Shari  E.  Redstone 

President,  National  Amusements,  Inc. 

E.  John  Rosenwald,  Jr. 

Vice  Chairman  Emeritus,  J.P.Morgan 

Michael  I.  Roth 

Chairman  and  CEO,  The  Interpublic  Group 
of  Companies,  Inc. 

Mara  Burros  Sandler 

Michael  P.  Schulhof 

Chairman,  GTI  Holdings  LLC 

Louis  W.  Sullivan,  M.D. 

President  Emeritus,  Morehouse  School  of  Medicine 
John  J.  Sweeney 
Clyde  C.  Tuggle 

Senior  Vice  President,  Chief  Public  Affairs  and 
Communications  Officer,  The  Coca-Cola  Company 

Donald  R.  Keough  (1992-2010) 

LaSalle  D.  Leffall,  Jr.,  M.D.,  F.A.C.S.  (1992-2001) 

Nancy  Reagan  (1995-2000) 

Linda  Johnson  Rice  (1992-1996) 

George  Rupp,  Ph.D.  (1993-2002) 

Michael  I.  Sovern  (1992-1993) 

Frank  G.  Wells  (1992-1994) 

Michael  A.  Wiener  (1997-2009) 


Copyright  ©2012.  All  rights  reserved.  May  not  be  used  or  reproduced  without  the  express  written  permission  of  The  National  Center 
on  Addiction  and  Substance  Abuse  at  Columbia  University. 


The  CASA  Columbia  National  Advisory  Commission  on  Addiction  Treatment 


Drew  E.  Altman,  PhD  (Chair) 
President  and  Chief  Executive  Officer 
The  Henry  J.  Kaiser  Family  Foundation 

Harvey  V.  Fineberg,  MD,  PhD 
President 

Institute  of  Medicine 
Mark  S.  Gold,  MD 

University  of  Florida  College  of  Medicine 
and  McKnight  Brain  Institute 
Departments  of  Psychiatry,  Neuroscience, 
Anesthesiology,  Community  Health  &  Family 
Medicine 

Chairman,  Department  of  Psychiatry 

Shelly  F.  Greenfield,  MD,  MPH 

Chief  Academic  Officer,  McLean  Hospital 

Professor  of  Psychiatry, 

Harvard  Medical  School 

Director,  Clinical  and  Health  Services  Research 
and  Education 

Division  on  Alcohol  and  Drug  Abuse, 
McLean  Hospital 

Elizabeth  R.  Kabler 
President 

Rosenstiel  Foundation 

Myles  V.  Lynk,  JD 

Peter  Kiewit  Foundation 

Professor  of  Law  and  the  Legal  Profession 

Faculty  Fellow,  Center  for  Law,  Science  & 

Innovation's  Program  in  Public  Health  Law 

and  Policy 

Sandra  Day  O'Connor  College  of  Law 
Arizona  State  University 


June  E.  Osborn,  MD 

President  Emerita 

Josiah  Macy,  Jr.  Foundation 

Manuel  T.  Pacheco,  PhD 

President  Emeritus,  University  of  Arizona 

and  University  of  Missouri  System 

The  Honorable  Jose  R.  Rodriguez 
Circuit  Judge 

Ninth  Judicial  Circuit  of  Florida 

Reverend  Msgr.  Stephen  J.  Rossetti,  PhD,  DM  in 

Clinical  Associate  Professor 

Associate  Dean  for  Seminary 

and  Ministerial  Programs 

The  Catholic  University  of  America, 

The  School  of  Theology  and  Religious  Studies 

Former  President  and  Chief  Executive  Officer 

Saint  Luke  Institute,  Inc. 

Leonard  D.  Schaeffer 
Judge  Robert  Maclay  Widney 
Chair  &  Professor 
University  of  Southern  California 

Steven  A.  Schroeder,  MD 

Distinguished  Professor  of  Health  and  Health 

Care,  Department  of  Medicine 

Director,  Smoking  Cessation  Leadership  Center 

University  of  California,  San  Francisco 

Louis  W.  Sullivan,  MD 
President  Emeritus 
Morehouse  School  of  Medicine 


Table  of  Contents 


Foreword  and  Accompanying  Statement  by  Drew  Altman,  PhD  i 

I.  Introduction  and  Executive  Summary  1 

The  CASA  Columbia  Study  4 

Key  Findings  6 

Addiction  Is  a  Brain  Disease  6 

As  with  Other  Health  Conditions,  There  Are  Clear  Risk  Factors  for 

the  Development  of  Addiction  7 

Addiction  Frequently  Co-Occurs  with  Other  Health  Conditions  7 

Addiction  Can  Be  a  Chronic  Disease  7 

A  Lack  of  Standardized  Terminology  Compromises  Effective  Interventions  7 

Multiple  Addictive  Substances  and  Behaviors  Frequently  Are  Involved  in 

Risky  Use  and  Addiction  7 

Public  Attitudes  about  the  Causes  of  Addiction  Are  Out  of  Sync  with  the  Science  8 

Physicians  and  Other  Health  Care  Providers  Should  Be  on  the  Front  Line  for 

Addressing  this  Disease  8 

Screening  and  Intervention  Are  Effective  at  Addressing 

Risky  Substance  Use  and  Forestalling  Addiction  9 

Effective  Therapies  to  Treat  and  Manage  Addiction  Exist  9 

The  Importance  of  Tailored  Interventions  and  Treatment  10 

Public  Attitudes  about  Addiction  Treatment  Reflect  the  Prevailing 

Non-Medical  Approach  to  Addiction  Care  10 

Most  People  in  Need  of  Treatment  Do  Not  Receive  It  10 

Most  Referrals  to  Publicly  Funded  Treatment  Come  from  the 

Criminal  Justice  System  1 1 

Less  than  Half  of  Treatment  Admissions  Result  in  Treatment  Completion  12 

Patients  Face  Formidable  Barriers  to  Receiving  Addiction  Treatment  12 

The  Spending  Gap  12 

Most  Funding  for  Addiction  Treatment  Comes  from  Public  Sources  13 

The  Education,  Training  and  Accountability  Gap  13 

The  Profound  Disconnect  between  Evidence  and  Practice  13 

Recommendations  and  Next  Steps  14 

Reform  Health  Care  Practice  14 

Use  the  Leverage  of  Public  Policy  to  Speed  Reform  in  Health  Care  Practice  15 

II.  What  Is  Addiction?  19 

Addiction  Is  a  Brain  Disease  20 

The  Risk  Factors  for  Addiction  22 

Genetic  Risks  22 

Biological  Risks  23 

Psychological  Risks  23 

Environmental  Risks  23 

Early  Initiation  of  Use  24 

Risky  Use  and  Addiction  Frequently  Co-Occur  with  Other  Health  Conditions  24 

Addiction  Can  Be  a  Chronic  Disease  25 


Models  for  Understanding  Addiction  26 

Evolving  Approaches  to  Addressing  Addiction  26 

Defining  the  Terms  29 

The  Continuum  of  Substance  Use  29 

Public  Attitudes  about  Addiction  34 

Perceived  Causes  of  Addiction  35 

III.  Prevalence  and  Consequences  39 

Defining  the  Problem  40 

Risky  Substance  Users  41 

Risky  Tobacco  Use  43 

Risky  Alcohol  Use  44 

Risky  Illicit  Drug  Use  46 

Risky  Use  of  Controlled  Prescription  Drugs  47 

Addiction  48 

Special  Populations  5 1 

Pregnant  Women  5 1 

Adolescents  and  Young  Adults  51 

Older  Adults  52 

Co-Occurring  Disorders  52 

Members  of  the  Military  Exposed  to  Combat  53 

Involvement  in  the  Justice  System  55 

Consequences  of  Risky  Substance  Use  and  Untreated  Addiction  55 

Tobacco  58 

Alcohol  59 

Illicit  Drugs  60 

Controlled  Prescription  Drugs  61 

IV.  Screening  and  Early  Intervention  63 

The  Need  for  Patient  Education,  Screening  and  Intervention  throughout  the  Lifespan  ....64 

Childhood  and  Adolescence  64 

Young  Adulthood  65 

Middle  and  Later  Adulthood  65 

Attending  to  Co-Occurring  Conditions  66 

Patient  Education  and  Motivation  66 

Screening  66 

Laboratory  Tests  68 

Brief  Interventions  and  Treatment  Referrals  69 

Tobacco  69 

Alcohol  and  Other  Drugs  70 

Effectiveness  of  Screening  and  Brief  Interventions  71 

Tobacco  72 

Alcohol  72 

Other  Drugs  73 

Implementing  Screening  and  Brief  Interventions  in  Health  Care  and  Other  Settings  74 

Primary  Care  74 

Emergency  and  Trauma  Care  76 

Health  Care  for  Pregnant  Women  77 


Mental  Health  Care  78 

Dental  Care  78 

Pharmacies  78 

High  School,  College  and  University  Settings  78 

Justice  Settings  79 

The  Workplace  80 

Government-Funded  Social  Service  Systems  81 

Barriers  to  Effective  Implementation  of  Screening  and  Brief  Interventions  81 

Insufficient  Training  81 

Competing  Priorities/Insufficient  Resources  82 

Inadequate  Screening  Tools  83 

V.  Treatment  and  Management  of  Addiction  85 

A  Comprehensive  Approach  to  Treatment  86 

Assessment  87 

Stabilization  88 

Cessation  of  Use  88 

Detoxification  89 

Acute  Care  92 

Pharmaceutical  Therapies  92 

Psychosocial  Therapies  102 

Combined  Therapies  104 

Nutrition  and  Exercise  106 

Chronic  Disease  Management  107 

Medically  Supervised  Disease  Management  107 

Case  Management  108 

Support  Services  109 

Mutual  Support  Services  109 

Auxiliary  Support  Services  113 

The  Use  of  Technology  in  Addiction  Treatment  and  Disease  Management  1 14 

Public  Attitudes  about  Addictive  Substances  and  the  Need  for  Addiction  Treatment....  1 14 
Perceptions  of  the  Relative  Need  for  Treatment  Based  on  Substance  of  Addiction  .1 14 

Perceptions  of  the  Goals  of  Treatment  115 

Perceptions  of  the  Types  of  Interventions  that  Constitute  Treatment  116 

Perceptions  of  the  Effectiveness  of  Treatment  116 

VI.  Tailored  Treatment  for  Special  Populations  119 

Co-occurring  Medical  Disorders  119 

Co-occurring  Mental  Health  Disorders  120 

Tobacco  Cessation  121 

Treatment  for  Addiction  Involving  Alcohol  and  Other  Drugs  121 

Adolescents  122 

Tobacco  Cessation  122 

Treatment  for  Addiction  Involving  Alcohol  and  Other  Drugs  123 

Women  124 

Pregnant  Women  124 

Older  Adults  125 

Racial  and  Ethnic  Minorities  126 


Individuals  of  Minority  Sexual  Orientation  126 

Veterans  and  Active  Duty  Military  127 

Individuals  Involved  in  the  Justice  System  128 

Juvenile  Offenders  128 

Adult  Corrections  128 

VII.  The  Addiction  Treatment  Gap  131 

Most  People  in  Need  of  Treatment  Do  Not  Receive  It  133 

Variations  in  the  Treatment  Gap  by  Primary  Substance  Involved  134 

Variations  in  the  Treatment  Gap  by  Key  Patient  Characteristics  135 

Regional  Variations  in  the  Treatment  Gap  137 

Sources  of  Funding  for  Addiction  Treatment  137 

Privately-Funded  Treatment  138 

Publically-Funded  Treatment  138 

Trends  in  Spending  on  Addiction  Treatment  139 

Expenditures  by  Providers  and  Types  of  Services  139 

Treatment  Admissions  141 

Treatment  Referrals  and  Venues  142 

Treatment  Completion  145 

Variations  in  Treatment  Completion  by  Source  of  Referral  146 

Variations  in  Treatment  Completion  by  Primary  Substance  Involved  146 

Variations  in  Treatment  Completion  by  Key  Patient  Characteristics  146 

Link  between  Funding  Source,  Type  of  Service  Provided  and  Treatment  Completion  ..146 

Barriers  Patients  Face  in  Accessing  and  Completing  Addiction  Treatment  147 

Misunderstanding  of  the  Disease  147 

Negative  Public  Attitudes  and  Behaviors  Toward  People  with  Addiction  148 

Privacy  Concerns  150 

Cost  151 

Lack  of  Information  about  How  To  Get  Help  152 

Limited  Availability  of  Services  152 

Insufficient  Social  Support  153 

Conflicting  Time  Commitments  153 

Negative  Perceptions  of  the  Treatment  Process  153 

Legal  Barriers  154 

Barriers  to  Treatment  Access  and  Completion  in  Special  Populations  154 

Individuals  with  Co-Occurring  Conditions  154 

Pregnant  and  Parenting  Women  155 

Adolescents  155 

Older  Adults  156 

The  Homeless  156 

Veterans  and  Active  Duty  Military  157 

Rural  Populations  157 

Native  Americans  158 


VIII.  The  Spending  Gap  159 

The  Rational  Approach  to  Risky  Substance  Use  and  Addiction  159 

Costs  of  Our  Failure  to  Prevent  and  Treat  Addiction  as  a  Medical  Condition  160 

The  Largest  Share  of  Costs  Falls  to  the  Health  Care  System  160 

Cost  Savings  of  Addiction  Screening,  Intervention  and  Treatment  161 

Screening  and  Early  Intervention  162 

Addiction  Treatment  and  Disease  Management  164 

Insurance  Coverage  of  Addiction  Treatment  is  Limited  166 

Parity  Laws  166 

The  Patient  Protection  and  Affordable  Care  Act  of  2010  168 

Gaps  in  Coverage  within  Public  and  Private  Insurance  Plans  Continue  to 
Impede  Comprehensive  Addiction  Care  169 

IX.  The  Education,  Training  and  Accountability  Gap  175 

The  Size  and  Shape  of  the  Addiction  Treatment  Workforce  176 

Licensing  and  Credentialing  Requirements  for  Individuals  who  Provide 

Addiction  Treatment  177 

Medical  Professionals  178 

Mental  Health  Professionals  183 

Acupuncturists  185 

Addiction  Counselors  186 

Licensure,  Certification  and  Accreditation  Requirements  for  Addiction  Treatment 

Programs  and  Facilities  187 

State  Licensing  Requirements  188 

Federal  Regulatory  Requirements  189 

Accreditation  Requirements  190 

Professional  Staffing  Requirements  191 

Treatment  Service  Requirements  193 

Quality  Assurance  Requirements  195 

X.  The  Evidence-Practice  Gap  199 

Current  Approaches  to  Risky  Substance  Use  and  Addiction  Are  Inconsistent 

with  the  Science  and  Evidence-Based  Care  199 

Patient  Education,  Screening,  Brief  Interventions  and  Treatment  Referrals  200 

Assessment,  Stabilization  and  Acute  Treatment  204 

Tailored  Treatment  Services  208 

Chronic  Disease  Management  210 

Barriers  to  Closing  the  Evidence-Practice  Gap  212 

The  Addiction  Treatment  Workforce  is  Not  Qualified  to  Implement 

Evidence-Based  Practices  212 

Health  Professionals  do  not  Implement  Evidence-Based  Addiction  Care  Practices  .216 

Inadequate  Use  and  Development  of  Pharmaceutical  Treatments  for  Addiction  219 

Inadequate  Quality  Assurance  220 

Inadequate  Insurance  Coverage  222 

No  Overarching  Organizing  Body  for  Addiction  Science  and  Treatment  223 

Efforts  to  Integrate  Substance  Use  Prevention  and  Treatment  into 
Mainstream  Medicine  223 


XL  Recommendations  and  Next  Steps  227 

Reform  Health  Care  Practice  228 

Incorporate  Screening  and  Intervention  for  Risky  Substance  Use, 
and  Diagnosis,  Treatment  and  Disease  Management  for  Addiction 

into  Routine  Medical  Practice  228 

All  Medical  Schools  and  Residency  Training  Programs  Should  Educate  and 

Train  Physicians  to  Address  Risky  Substance  Use  and  Addiction  229 

Require  Non-Physician  Health  Professionals  to  Be  Educated  and  Trained  to 

Address  Risky  Substance  Use  and  Addiction  229 

Develop  Improved  Screening  and  Assessment  Instruments  230 

Establish  National  Accreditation  Standards  for  All  Addiction  Treatment 

Facilities  and  Programs  that  Reflect  Evidence-Based  Care  230 

Standardize  Language  Used  to  Describe  the  Full  Spectrum  of  Substance  Use  and 

Addiction  230 

Use  the  Leverage  of  Public  Policy  to  Speed  Reform  in  Health  Care  Practice  231 

Condition  Grants  and  Contracts  for  Addiction  Services  on  the  Provision  of 

Quality  Care  231 

Educate  Non-Health  Professionals  about  Risky  Substance  Use  and  Addiction  23 1 

Identify  Patients  at  Risk  in  Government  Programs  and  Services  where  Costs  of 

Risky  Use  and  Addiction  Are  High  23 1 

Develop  Tools  to  Improve  Service  Quality  23 1 

License  Addiction  Treatment  Facilities  as  Health  Care  Providers  232 

Require  Adherence  to  National  Accreditation  Standards  that 

Reflect  Evidence-Based  Care  232 

Require  that  All  Insurers  Provide  Coverage  for  Comprehensive  Addiction  Care  232 

Expand  the  Addiction  Medicine  Workforce  232 

Implement  a  National  Public  Health  Campaign  233 

Invest  in  Research  and  Data  Collection  to  Improve  and  Track  Progress  in  Addiction 

Prevention,  Treatment  and  Disease  Management  233 

Implement  the  National  Institutes  of  Health's  (NIH)  Recommendation  to  Create  a 

Single  Institute  Addressing  Substance  Use  and  Addiction  234 

Appendix  A-Methodology  235 

Appendix  B-Key  Informant  Interview  Guide  and  List  of  Key  Informants  245 

Appendix  C-National  Addiction  Belief  and  Attitude  Survey  (NABAS)  253 

Appendix  D-Survey  of  New  York  State  Addiction  Treatment  Directors  269 

Appendix  E-Survey  of  New  York  State  Addiction  Treatment  Staff  285 

Appendix  F-  National  Panel  and  National  Online  Survey  of  Members  of  Professional 

Associations  Involved  in  Addiction  Care  297 

Appendix  G-Survey  of  Participants  in  Recovery  305 

Appendix  H- Screening  and  Assessment  Instruments  311 

Notes  325 

Bibliography  429 


Accompanying  Statement  by 

Drew  E.  Altaian,  PhD,  Chair,  The  CASA  Columbia 

National  Advisory  Commission  on  Addiction  Treatment 

In  homes,  doctors'  offices,  hospitals,  schools, 
prisons,  jails  and  communities  across  America, 
misperceptions  about  addiction  are  undermining 
medical  care.  Although  advances  in 
neuroscience,  brain  imaging  and  behavioral 
research  clearly  show  that  addiction  is  a 
complex  brain  disease,  today  the  disease  of 
addiction  is  still  often  misunderstood  as  a  moral 
failing,  a  lack  of  willpower,  a  subject  of  shame 
and  disgust.  Addiction  affects  16  percent  of 
Americans  ages  12  and  older— 40  million  people. 
That  is  more  than  the  number  of  people  with 
heart  disease  (27  million),  diabetes  (26  million) 
or  cancer  (19  million).  Another  32  percent  of 
the  population  (80  million)  uses  tobacco,  alcohol 
and  other  drugs  in  risky  ways  that  threaten 
health  and  safety. 


Like  other  public  health  and  medical  problems, 
we  understand  the  risk  factors  for  addiction.  We 
have  effective  ways  of  screening  for  risky  use 
and  intervening.  While  as  of  now  there  is  no 
cure  for  addiction,  there  are  effective 
psychosocial  and  pharmaceutical  treatments  and 
methods  of  managing  the  disease.  But  as  this 
landmark  report  by  CASA  Columbia  shows  in 
sharp  detail,  this  is  where  the  comparison  with 
other  health  conditions  ends.  Unlike  other 
diseases,  we  do  little  to  effectively  prevent  and 
reduce  risky  use  and  the  vast  majority  of  people 
in  need  of  addiction  treatment  do  not  receive 
anything  that  approximates  evidence-based  care. 

The  medical  system,  which  is  dedicated  to 
alleviating  suffering  and  treating  disease,  largely 
has  been  disengaged  from  these  serious  health 
care  problems.  The  consequences  of  this 
inattention  are  profound.  America's  failure  to 
prevent  risky  use  and  effectively  treat  addiction 
results  in  an  enormous  array  of  health  and  social 
problems  such  as  accidents,  homicides  and 
suicides,  child  neglect  and  abuse,  family 
dysfunction  and  unplanned  pregnancies.  CASA 
Columbia  estimates  that  risky  substance  use  and 


-i- 


addiction  are  this  nation's  largest  preventable 
and  most  costly  health  problems,  accounting  for 
one  third  of  hospital  inpatient  costs,  driving 
crime  and  lost  productivity  and  resulting  in  total 
costs  to  government  alone  of  at  least  $468 
billion  each  year. 

In  many  ways,  America's  approach  to  addiction 
treatment  today  is  similar  to  the  state  of 
medicine  in  the  early  1900s.  In  1908,  the 
Council  on  Medical  Education  of  the  American 
Medical  Association  turned  to  the  Carnegie 
Foundation  for  the  Advancement  of  Teaching  to 
conduct  a  survey  of  Medical  Education  in  the 
U.S.  That  survey,  which  became  known  as  the 
Flexner  Report,  was  led  by  Abraham  Flexner 
who  famously  observed  of  the  discrepancy 
among  physicians'  qualifications,  "there  is 
probably  no  other  country  in  the  world  in  which 
there  is  so  great  a  distance  and  so  fatal  a 
difference  between  the  best,  the  average  and  the 
worst."  This  CASA  Columbia  report  identifies  a 
similar  gulf  in  the  knowledge  and  practice  skills 
of  addiction  treatment  providers  today.  The 
education  and  training  of  persons  providing 
addiction  treatment  vary  considerably  by  state. 
In  many  cases,  entry  requirements  for  the 
profession  are  minimal  in  terms  of  education  and 
are  based  on  apprenticeship  models  rather  than 
on  science-based  instruction. 

Flexner  noted  that  the  turn  of  the  19th  to  20th 
century  was  a  time  of  scientific  progress  in  the 
understanding  of  disease  and  its  treatment; 
however,  due  to  the  lack  of  a  standardized  and 
rigorous  education  for  physicians,  society  reaped 
"but  a  small  fraction  of  the  advantage  which 
current  knowledge  has  the  power  to  confer." 
Similarly,  1 00  years  later,  advances  in  science 
and  medicine  have  drawn  a  much  clearer  picture 
of  addiction-including  its  causes,  correlates  and 
how  to  treat  it— yet  we  are  woefully  unprepared 
to  apply  this  evidence  to  practice.  Our  medical 
professionals  are  not  trained  to  look  for  risky  use 
and  addiction  or  to  intervene  or  treat  the  disease. 
Without  medical  attention,  the  disease 
progresses,  forcing  doctors  to  expend  valuable 
resources  treating  the  more  than  70  other 
conditions  requiring  medical  attention  that  result 
from  substance  use  and  addiction,  while 
taxpayers  shoulder  the  costs  of  these  health  and 


other  social  consequences.  This  neglect  by  the 
medical  system  has  led  to  the  creation  of  a 
separate  and  unrelated  system  of  addiction  care 
that  struggles  to  treat  the  disease  without  the 
resources  or  the  knowledge  base  to  keep  pace 
with  science  and  medicine. 

Because  addiction  affects  cognition  and  is 
associated  primarily  with  the  difficult  social 
consequences  that  result  from  our  failure  to 
prevent  and  treat  it,  those  who  suffer  from  the 
disease  are  poor  advocates  for  their  own  health. 
And  due  in  large  part  to  the  shame,  stigma  and 
discrimination  attached  to  the  disease, 
individuals  with  addiction  and  their  family 
members  too  often  are  isolated  in  their  struggle 
to  understand  the  disease  and  find  help.  Only 
recently  have  we  begun  to  see  those  affected  by 
the  disease  working  to  raise  awareness  in  ways, 
for  example,  that  families  of  breast  cancer 
victims  have  done.  But  these  efforts  are  small, 
challenged  by  public  misunderstanding  and  have 
failed  to  raise  sufficient  funding  for  needed 
research. 

Even  individuals  who  can  transcend  the  stigma 
face  significant  barriers  to  receiving  effective 
care,  and  this  report  paints  a  dismal  picture  of  a 
treatment  'non-system. '  While  almost  half  of 
Americans  say  they  would  go  to  their  health  care 
providers  for  help,  most  doctors  are  uninformed 
about  this  disease  and  rarely  are  equipped  to 
offer  a  diagnosis,  provide  treatment  or  connect 
patients  with  appropriate  specialty  care. 
Insurance  coverage  varies  widely.  Services 
rarely  are  tailored  to  individual  needs  and  are 
based  primarily  on  an  acute  care  model  rather 
than  recognizing  the  chronic  nature  of  the 
disease.  There  are  no  national  standards  of  care. 
Patients  face  a  patchwork  of  treatment  programs 
with  vastly  different  approaches;  many  offer 
unproven  therapies  and  little  medical 
supervision.  Some  promise  "one  time"  fixes; 
others  offer  posh  residential  treatment  at 
astronomical  prices  with  little  evidence 
justifying  the  cost.  Even  for  those  who  do  have 
insurance  coverage  or  can  pay  out-of-pocket, 
there  are  no  outcome  data  reflecting  the  quality 
of  treatment  providers  so  that  patients  can  make 
informed  decisions. 


-n- 


This  report  focuses  long  overdue  attention  on  the 
disease  of  addiction.  It  clarifies  the  important 
difference  between  this  disease  and  risky  use  of 
addictive  substances;  identifies  the  human  and 
economic  costs  of  our  current  approach  to  these 
health  problems;  and  documents  the  breadth  of 
available  knowledge  on  how  to  prevent  risky  use 
and  treat  addiction. 

As  our  nation  struggles  to  reduce  skyrocketing 
health  care  costs,  there  are  few  targets  for  cost 
savings  that  are  as  straightforward  as  preventing 
and  treating  risky  substance  use  and  addiction. 
This  report  shows  that  modest  public  health 
interventions  and  relatively  inexpensive 
addiction  therapies,  compared  with  other 
medical  treatments,  would  reduce  this  burden 
significantly. 

The  report  calls  for  modernizing  addiction 
treatment-to  harness  the  scientific  knowledge 
we  have  acquired  to  prevent  risky  use  and  treat 
this  disease.  This  report  is  a  call  to  action.  Like 
the  Flexner  Report  a  century  ago,  it  shines  a 
bright  light  on  the  problem  and  offers  a  roadmap 
for  action.  Addiction  Medicine:  Closing  the  Gap 
between  Science  and  Practice  represents  more 
than  five  years  of  intensive  research,  and  draws 
on  policy  and  treatment  research  conducted  by 
CASA  Columbia  over  two  decades  and  on  a 
wide  body  of  scientific,  clinical  and  policy 
research  conducted  by  others.  This  major 
undertaking  was  the  result  of  the  work  of  a  large 
team  of  dedicated  individuals  and  institutions 
and  was  conducted  with  the  able  advice  and 
counsel  of  The  CASA  Columbia  National 
Advisory  Commission  on  Addiction  Treatment 
which  1  had  the  privilege  to  chair.  The 
Commission  includes  an  impressive  group  of 
individuals  knowledgeable  about  the  many 
aspects  of  substance  use  and  addiction  in 
America  today.  We  are  grateful  for  their  expert 
assistance. 

The  project  was  made  possible  by  the  generous 
financial  support  of  The  Annenberg  Foundation; 
The  Diana,  Princess  of  Wales  Memorial  Fund 
and  The  Franklin  Mint;  The  New  York 
Community  Trust;  and  the  Adrian  and  Jessie 
Archbold  Charitable  Trust. 


Peter  D.  Hart  Research  Associates  conducted  the 
National  Addiction  Belief  and  Attitude  Survey 
for  this  report;  Survey  Research  Laboratory 
(SRL)  of  the  University  of  Illinois  at  Chicago 
administered  the  survey  of  New  York  State 
addiction  treatment  providers.  We  are  grateful 
to  Karen  Carpenter-Palumbo,  former  director  of 
the  New  York  State  Office  of  Alcoholism  and 
Substance  Abuse  Services  (OASAS)  for  helping 
to  make  the  New  York  State  survey  possible. 

We  thank  the  following  organizations  which 
generously  helped  connect  CASA  Columbia 
with  treatment  providers  who  participated  in  a 
national  online  survey  of  members  of 
professional  associations  involved  in  addiction 
care:  The  American  Academy  of  Addiction 
Psychiatry  (AAAP);  the  American  Association 
for  the  Treatment  of  Opioid  Dependence 
(AATOD);  the  American  Psychological 
Association  (APA);  the  American  Society  of 
Addiction  Medicine  (ASAM);  the  Association 
for  the  Treatment  of  Tobacco  Use  and 
Dependence  (ATTUD);  NAADAC,  the 
Association  for  Addiction  Professionals;  the 
National  Association  of  Addiction  Treatment 
Providers  (NAATP);  the  National  Association  of 
County  Behavioral  Health  and  Developmental 
Disability  Directors  (NACBHDD);  the  National 
Council  for  Community  Behavioral  Healthcare 
(National  Council);  the  State  Associations  of 
Addiction  Services  (SAAS);  and  Treatment 
Communities  of  America  (TCA).  Also,  we 
thank  the  following  organizations  for  connecting 
us  with  individuals  in  long-term  recovery  for 
CASA  Columbia's  online  survey  of  this 
population:  Hazelden,  Freedom  Institute,  Faces 
and  Voices  of  Recovery,  Betty  Ford  Center, 
National  Council  on  Alcoholism  and  Drug 
Dependence,  Inc.  (NCADD),  Treatment 
Communities  of  America  (TCA),  Alcoholism 
and  Substance  Abuse  Providers  of  New  York 
State,  Inc.  (ASAP)  and  an  anonymous  treatment 
program  alumni  group.  Finally,  we  are  grateful 
to  the  1 76  key  informants  who  shared  their 
insight  and  recommendations. 

Susan  E.  Foster,  MSW,  CASA  Columbia's  Vice 
President  and  Director  of  Policy  Research  and 
Analysis,  was  the  principal  investigator  and  staff 
director  for  this  effort.  The  senior  research 


-iii- 


manager  was  Linda  Richter,  PhD,  Associate 
Director  of  the  Division  and  CASA  Columbia 
Scholar.  The  data  collection  and  analysis  was 
conducted  by  CASA  Columbia's  Data  Analysis 
Center  (SADACSM),  headed  by  Roger  Vaughan, 
DrPH,  CASA  Columbia  Fellow  and  Professor  of 
Clinical  Biostatistics,  Department  of 
Biostatistics,  Mailman  School  of  Public  Health 
at  Columbia  University,  and  associate  editor  for 
statistics  and  evaluation  for  the  American 
Journal  of  Public  Health.  He  was  assisted  by 
Elizabeth  Peters  and  Sarah  Tsai,  MA.  Emily 
Feinstein,  JD,  senior  policy  analyst,  assisted 
with  the  research  and  writing.  Other  research 
staff  members  who  worked  on  the  project  are: 
Nina  Lei,  Mark  Stovell,  Akiyo  Kodera,  Dina 
Feivelson,  PhD,  Gina  Hijjawi,  PhD,  Harold 
Wenglinsky,  PhD,  Swapna  Reddy,  JD,  Kristen 
Keneipp,  MHS,  Nabil  Ansari  and  Sarah 
Blachman.  David  Man,  PhD,  MLS,  is  CASA 
Columbia's  librarian;  he  was  assisted  by  Barbara 
Kurzweil.  Jennie  Hauser  managed  the 
bibliographic  database  and  Jane  Carlson  handled 
administrative  details. 

While  many  individuals  and  institutions 
contributed  to  this  effort,  the  findings  and 
opinions  expressed  herein  are  the  sole 
responsibility  of  CASA  Columbia. 


Chapter  I 

Introduction  and  Executive  Summary 


A  large  and  growing  body  of  scientific  research 
has  demonstrated  clearly  that  addiction 
involving  nicotine,  alcohol,  illicit  drugs  and 
controlled  prescription  drugs  is  a  complex  brain 
disease.1  It  affects  15.9  percent  of  the  United 
States  population  ages  12  and  older  (40.3 
million)1 2— more  than  the  share  of  the 
population  with  heart  disease,*  diabetes  or 
cancer.3  Another  3 1 .7  percent  of  the  population 
(80.4  million),  while  not  addicted,  engages  in 
risky  use§  of  addictive  substances  in  ways  that 
threaten  health  and  safety.4 


In  this  report,  we  have  used  the  general  term 
addiction  to  apply  to  those  who  meet  criteria  for  past- 
month  nicotine  dependence  based  on  the  Nicotine 
Dependence  Syndrome  Scale  (NDSS)  and  those  who 
meet  diagnostic  criteria  for  past  year  alcohol  and/or 
other  drug  abuse  or  dependence  (excluding  nicotine) 
in  accordance  with  the  Diagnostic  and  Statistical 
Manual  of  Mental  Disorders  (DSM-IV).  (The  DSM, 
the  most  widely  accepted  diagnostic  system  in  the 
U.S.  for  such  conditions,  refers  to  substance  abuse 
and  substance  dependence  collectively  as  substance 
use  disorders.  The  diagnostic  criteria  for  nicotine 
dependence  in  the  NDSS  parallel  those  of  the  DSM- 
IV).  This  definition  is  consistent  with  the  current 
move  to  combine  abuse  and  dependence  into  an 
overarching  diagnosis  of  addiction  in  the  upcoming 
DSM-V.  The  term  addiction  also  has  been  used  in 
reference  to  compulsive  behaviors  involving  eating, 
gambling  and  other  activities  that  affect  the  brain's 
reward  system  and  which  may  develop  independent 
of  or  in  combination  with  other  manifestations  of 
addiction.  This  report,  however,  focuses  only  on 
addiction  involving  nicotine,  alcohol  and  other  drugs. 

*  This  estimate  excludes  the  institutionalized 
population,  for  which  rates  of  addiction  are  higher. 

*  Includes  coronary  heart  disease,  angina  pectoris, 
heart  attack  or  any  other  heart  condition  or  disease, 
excluding  hypertension  and  stroke. 

§  Risky  users  of  addictive  substances  are  defined  in 
this  report  as  those  who  currently  use  tobacco 
products,  exceed  the  U.S.  Department  of  Agriculture 
(USDA)  Dietary  Guidelines  for  safe  alcohol  use, 
misuse  controlled  prescription  drugs,  use  illicit  drugs, 
or  engage  in  some  combination  of  these  forms  of 
substance  use,  but  do  not  meet  clinical  diagnostic 
criteria  for  addiction.  (See  page  5.) 


-1- 


Addiction  and  risky  use  constitute  the  largest 
preventable  and  most  costly  health  problems 
facing  the  U.S.  today.5  It  is  estimated  that  more 
than  20  percent  of  deaths  in  the  U.S.  are 
attributable  to  tobacco,  alcohol  and  other  drug 
use.6  Addiction  and  risky  use  cause  or 
contribute  to  more  than  70  other  conditions 
requiring  medical  care,  including  cancer, 
respiratory  disease,  cardiovascular  disease, 
HIV/AIDS,  pregnancy  complications,  cirrhosis, 
ulcers  and  trauma.7  They  also  drive  and 
contribute  to  a  wide  range  of  costly  social 
consequences,  including  crime,  accidents, 
suicide,  child  neglect  and  abuse,  family 
dysfunction,  unplanned  pregnancies  and  lost 
productivity.8  Costs  of  addiction  and  risky 
substance  use  to  government  alone  total  at  least 
$468  billion  each  year.9 

While  both  addiction  and  risky  use  of  addictive 
substances  contribute  to  these  consequences, 
they  are  very  different  conditions.  Addiction  is 
a  disease  and,  like  other  diseases,  it  can  and 
should  be  diagnosed  and  treated  in  the  context  of 
the  medical  system,  using  available  evidence- 
based  practices.  Risky  use  of  addictive 
substances  is  a  public  health  problem  and  tools 
are  available  for  a  wide  range  of  professionals  in 
the  health,  social  services,  education,  criminal 
justice  and  other  sectors  to  screen  for  it  and 
intervene  to  reduce  it  and  its  consequences, 
including  the  potential  development  of 
addiction. 

Despite  the  prevalence  of  these  conditions,  the 
enormity  of  the  consequences  that  result  from 
them  and  the  availability  of  effective  solutions, 
screening  and  early  intervention  for  risky 
substance  use  is  rare  and  the  vast  majority  of 
people  in  need  of  addiction  treatment  do  not 
receive  anything  that  approximates  evidence- 
based  care.  Nine  out  of  10  people  (89. 1  percent) 
who  meet  diagnostic  criteria  for  addiction 


Involving  interdisciplinary  teams  of  physicians  (of 
multiple  medical  specialties  and  subspecialties), 
nurses,  physician  assistants,  nurses  and  nurse 
practitioners  and  graduate-level  clinical  mental  health 
professionals  (psychologists,  social  workers, 
counselors),  working  collaboratively  with  auxiliary 
and  support  personnel. 


involving  alcohol  and  drugs  other  than  nicotine 
report  receiving  no  treatment'  at  all;10  as  a 
society,  we  do  not  even  collect  information  on 
the  number  of  people  receiving  treatment  for 
addiction  involving  nicotine.  There  is  no  other 
disease  that  affects  so  many  people,  has  such 
far-reaching  consequences  and  for  which  there  is 
such  a  broad  range  of  effective  interventions  and 
treatments  that  is  as  neglected  as  the  disease  of 
addiction. 

This  report  documents  the  significant  body  of 
evidence  defining  and  describing  the  disease  of 
addiction  and  the  risky  use  of  addictive 
substances.  It  reveals  the  size  and  shape  of  the 
populations  in  need  of  screening,  intervention 
and  treatment.  It  reviews  the  evidence  of 
effective  screening,  intervention,  diagnostic, 
treatment  and  disease  management  tools  and 
therapies.  It  outlines  the  consequences  and  costs 
of  our  failure  to  prevent  risky  substance  use  and 
treat  addiction  effectively.  Finally,  it  examines 
the  profound  gaps  between  those  who  need 
treatment  and  those  who  receive  it,  and  between 
the  services  they  receive  and  what  constitutes 
quality  care. 

Key  factors  driving  these  gaps  include: 

•    Inadequate  Integration  of  Addiction  Care 
into  Mainstream  Medical  Practice: 

Addiction  prevention  and  treatment  are  for 
the  most  part  removed  from  routine  medical 
practice.11  In  spite  of  the  fact  that  about  80 
percent  of  Americans1  visited  at  least  one 
physician  or  other  health  care  professional  in 


*  Treatment  is  defined  in  this  report  as  psychosocial 
and  pharmaceutical  therapies.  Detoxification,  mutual 
support  programs,  peer  counseling,  other  support 
services  (including  religious-based  counseling)  and 
services  received  in  an  emergency  department  are 
excluded  from  the  definition.  Services  provided  in 
prison  or  jail  settings  also  are  excluded  since  they 
cannot  be  identified  in  the  data  sources  used  for  this 
analysis;  furthermore,  in  CAS  A  Columbia's  2010 
report  {Behind  Bars  Update:  Substance  Abuse  and 
America 's  Prison  Population),  more  than  70  percent 
of  those  receiving  addiction-related  services  in 
prisons  and  jails  received  support  services  rather  than 
any  form  of  professional  treatment. 

*  Ages  1 8  and  older. 


-2- 


the  past  year,    and  more  than  two-thirds  of 
people  with  addiction  are  estimated  to  be  in 
contact  with  a  primary  or  emergency  care 
physician  about  twice  a  year,13  most 
physicians  and  other  health  professionals 
do  not  identify  or  diagnose  the  disease  or 
know  what  to  do  with  patients  who  present 
with  identifiable  and  treatable  signs  and 
symptoms.  And,  unlike  other  diseases, 
physicians  too  often  lack  access  to  available, 
trained  and  certified  addiction  physician 
specialists  for  consultation  or  referral. 
Instead  of  addressing  addiction,  the  medical 
field  primarily  has  focused  its  efforts  on 
treating  the  secondary  and  tertiary 
complications  of  addiction,  allowing  the 
public  health  epidemic  to  advance 
unchecked.  Furthermore,  whereas  the  main 
criterion  for  determining  whether  health  care 
services  should  be  provided  to  patients  in 
mainstream  medicine  is  the  principle  of 
medical  necessity,14  patients  needing 
addiction  treatment  may  face  stringent 
eligibility  criteria  for  treatment  entry, 
including  insurance  benefit  restrictions, 
limited  availability  of  treatment  slots,  long 
waiting  lists,  lack  of  child  care  and  the 
requirement  to  comply  with  all  rules  and 
treatment  protocols.15  There  simply  is  no 
other  disease  where  appropriate  medical 
treatment  is  not  provided  by  the  health  care 
system  and  where  patients  instead  must  turn 
to  a  broad  range  of  practitioners  largely 
exempt  from  medical  standards. 

•    Inadequate  Education  and  Training  of 
Addiction  Treatment  Providers:  The 

majority  of  those  who  currently  make  up  the 
addiction  treatment  provider  workforce  are 
not  equipped  with  the  knowledge,  skills  or 
credentials  necessary  to  provide  the  full 
range  of  evidence-based  services  to  treat  the 
disease. 


The  term  "health  professional"  as  used  in  this  report 
includes  medical  professionals  (physicians,  physician 
assistants,  nurses  and  nurse  practitioners,  dentists, 
pharmacists)  and  graduate-level  clinical  mental 
health  professionals  (psychologists,  social  workers, 
counselors). 


>  Addiction  counselors,  who  make  up  the 
largest  share  of  providers  of  addiction 
treatment  services,  provide  care  for 
patients  with  a  medical  disease  yet  they 
are  not  required  to  have  any  medical 
training  and  most  states  do  not  require 
them  to  have  advanced  education  of  any 
sort.' 

>  Physicians  and  other  medical 
professionals,  who  make  up  the  smallest 
share  of  providers  of  addiction  treatment 
services,  receive  little  education  or 
training  in  addiction  science,  prevention 
and  treatment. 


•    Inadequate  Accountability  for  Addiction 
Treatment  Providers:  Addiction  treatment 
providers,  facilities  and  programs  are  not 
adequately  regulated  or  held  accountable  for 
providing  treatment  consistent  with  medical 


Only  six  states  require  a  bachelor's  degree  and  only 
one  state  requires  a  master's  degree. 


Published  in  the 

American  Journal  of  Public  Health 
July,  1919 

There  is  urgent  need  for  widespread  and  early 
education  of  the  medical  profession, 
legislators,  administrative  authorities  and  laity 
into  the  facts  of  addiction  disease. . . 

As  a  definite  clinical  entity  of  physical 
disease,  addiction  is  practically  untaught  in 
the  school  and  unappreciated  by  the  average 
medical  man. . . 

In  the  light  of  available  clinical  information 
and  study  and  in  the  light  of  competent 
laboratory  research  we  are  forced  as  a 
profession  to  admit  that  we  have  not  treated 
our  addiction  sufferers  with  sympathetic 
understanding  and  clinical  competency  and 
that  the  blame  for  the  past  failure  to  control 
the  [narcotic]  drug  problem  rests  largely  upon 
the  educational  inadequacy  of  our  medical 
profession,  and  institutions  of  scientific  and 
public  health  education.16 

-Ernest  S.  Bishop,  MD,  FACP 


-3- 


standards  and  proven  treatment  practices. 
The  credentials  of  treatment  providers  vary 
dramatically  from  state  to  state  and  from 
program  to  program.  Compounding  the 
problem,  quality  assurance  standards  that  do 
exist  focus  more  on  administrative  processes 
than  on  measureable  patient  outcomes. 

•    Inadequate  Allocation  of  Financial 
Resources:  Financial  investments  in 
addressing  addiction  and  risky  substance  use 
are  aimed  disproportionately  at  coping  with 
their  costly  health  and  social  consequences 
rather  than  at  the  effective  implementation 
of  available  prevention,  intervention  and 
treatment  approaches.  In  2010,  only  1.0 
percent  ($28.0  billion)  of  total  health  care 
costs  went  to  treating  the  disease  of 
addiction.17  Spending  on  addiction 
treatment  disproportionately  falls  to  the 
public  sector.  In  contrast  to  the  role  of 
private  insurance  in  general  health  care 
spending-where  it  covers  54.4  percent  of 
costs-private  insurers  cover  only  20.8 
percent  of  the  costs  of  addiction  treatment, 
and  the  private  share  has  been  decreasing.18 

This  profound  gap  between  the  science  of 
addiction  and  current  practice  related  to 
prevention  and  treatment  is  a  result  of  decades 
of  marginalizing  addiction  as  a  social  problem 
rather  than  treating  it  as  a  medical  condition. 
Much  of  what  passes  for  "treatment"  of 
addiction  bears  little  resemblance  to  the 
treatment  of  other  health  conditions.  Much  of 
what  is  offered  in  addiction  "rehabilitation" 
programs  has  not  been  subject  to  rigorous 
scientific  study  and  the  existing  body  of 
evidence  demonstrating  principles  of  effective 
treatment  has  not  been  taken  to  scale  or 
integrated  effectively  into  many  of  the  treatment 
programs  operating  nationwide.  This  is 
inexcusable  given  decades  of  accumulated 
scientific  evidence  attesting  to  the  fact  that 
addiction  is  a  brain  disease  with  significant 
behavioral  components  for  which  there  are 
effective  interventions  and  treatments.  It  also  is 
unfair  to  the  thousands  of  addiction  counselors 
who  struggle,  in  the  face  of  extreme  resource 
limitations  and  no  medical  training,  to  provide 


help  to  patients  with  the  disease  of  addiction  and 
numerous  co-occurring  medical  conditions. 

America's  tendency  to  frame  risky  use  of 
addictive  substances  and  addiction  as  the  same 
issue  and  as  moral  or  social  problems  has 
resulted  in  an  unmitigated  failure  on  the  part  of 
policymakers  and  the  health  care  community  to 
educate  the  public  about  these  health  problems 
in  ways  that  can  help  prevent  them  and  to  offer 
effective  interventions  and  treatments  that  match 
those  offered  for  other  health  conditions;  instead 
the  focus  has  weighed  heavily  toward  law 
enforcement.  The  end  result  is  that  we  have 
declared  war  on  drugs  rather  than  mounting  a 
rational  approach  to  prevention,  treatment  and 
finding  a  cure  for  the  disease  of  addiction.  We 
largely  have  punished  rather  than  treated  those 
in  need  of  help  even  though  treatment  for  a 
disease  and  accountability  for  behavior  are  not 
antithetic  concepts. 

It  is  long  past  time  for  health  care  practice  to 
catch  up  with  the  science.  Failure  to  do  so  is  a 
violation  of  medical  ethics,  a  cause  of  untold 
human  suffering  and  a  profligate  misuse  of 
taxpayer  dollars. 

The  CASA  Columbia  Study 

Substance  use  can  be  understood  as  a  continuum 
ranging  from  having  never  used  tobacco,  alcohol 
or  another  drug  at  one  end  to  having  an 
unmanaged  chronic,  relapsing  disease'  at  the 
other.  (Figure  LA) 


Including  any  use  of  illicit  drugs  or  the  misuse  of 
controlled  prescription  drugs. 
f  This  continuum  focuses  on  substance  use;  the 
category  labeled  addiction  includes  those  individuals 
who  meet  current  clinical  criteria  for  this  disease  but 
does  not  include  all  individuals  with  addiction. 


-4- 


Figure  1  .A 

Continuum  of  Substance  Use 

Percent  of  Population  Age  12+ 
by  Level  of  Substance  Use* 


12.7 

25.2 

14.5 

31.7 

Never 
Used 

No 
Current 
Use 

Non- 
Risky  Use 

Risky 
Use 

*  Includes  tobacco,  alcohol,  illicit  drugs  and  misuse  of 
controlled  prescription  drugs. 

Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  201 0. 


Guidelines  for  safe  alcohol  use/  20  misuse 
controlled  prescription  drugs,5  use  illicit 
drugs"  21  or  engage  in  some  combination  of 
these  forms  of  substance  use  but  do  not 
meet  clinical  diagnostic  criteria  for 
addiction.  Risky  use  can  result  in 
devastating  and  costly  health  and  social 
consequences  including  the  disease  of 
addiction.  Risky  users  are  targets  for  public 
health  efforts  aimed  at  reducing  risky  use 
and  for  health  professionals'  efforts  to 
prevent  risky  use  from  progressing  to  the 
disease  of  addiction.  Approximately  one- 
third  (31.7  percent)  of  the  U.S.  population 
ages  12  and  older  (80.4  million  people)  are 
risky  substance  users.22 


While  this  report  focuses  primarily  on  those  with 
the  disease  of  addiction,  it  makes  an  important 
distinction  between  addiction  and  risky  use  of 
addictive  substances: 

•  Those  with  the  active  disease  of  addiction* 
are  defined  in  this  report  as  meeting  the 
clinical  diagnostic  criteria  for  past  month 
nicotine  dependence  or  past  year  alcohol 
and/or  other  drug  abuse  or  dependence. 
Individuals  who  meet  diagnostic  criteria  for 
addiction  are  targets  for  appropriate, 
evidence-based  clinical  interventions  by 
physicians  and  other  health  professionals. 
Addiction  afflicts  15.9  percent  of  the  U.S. 
population  ages  12  and  older  (40.3  million 
people).19 

•  Risky  users  of  addictive  substances  are 
defined  in  this  report  as  those  who  currently' 
use  tobacco  products,  exceed  the  U.S. 
Department  of  Agriculture  (USDA)  Dietary 


Available  data  allow  us  to  include  only  those  who 
meet  behavioral  criteria  in  accordance  with  the 
diagnostic  standards,  meaning  in  most  cases  that  their 
disease  is  not  currently  being  managed.  Individuals 
who  have  the  disease  of  addiction  but  do  not  meet 
diagnostic  criteria  for  past  month  (nicotine)  or  past 
year  (alcohol  and  other  drug)  addiction  are  not 
included. 

1  In  the  past  30  days. 


1  The  U.S.  Department  of  Agriculture  Dietary 
Guidelines  for  safe  alcohol  use  are  no  more  than  one 
drink  a  day  for  women,  no  more  than  two  drinks  a 
day  for  men  and  no  alcohol  consumption  for: 
(1)  persons  under  the  age  of  21;  (2)  pregnant  women; 
(3)  individuals  who  cannot  restrict  their  drinking  to 
moderate  levels;  (4)  individuals  taking  prescription  or 
over-the-counter  medications  that  can  interact  with 
alcohol;  (5)  individuals  with  certain  specific  medical 
conditions  (e.g.,  liver  disease,  hypertriglyceridemia, 
pancreatitis);  and  (6)  individuals  who  plan  to  drive, 
operate  machinery,  or  take  part  in  other  activities  that 
require  attention,  skill  or  coordination  or  in  situations 
where  impaired  judgment  could  cause  injury  or  death 
(e.g.,  swimming).  Due  to  data  limitations,  we  were 
unable  to  include  categories  4-6  in  our  calculation  of 
risky  drinkers. 

§  For  data  analysis  purposes,  the  national  survey 
examined  for  this  report  defines  misuse  of  controlled 
prescription  medications  more  generally  as  "taking  a 
controlled  prescription  drug  not  prescribed  for  you  or 
taking  it  in  a  manner  not  prescribed  for  the 
experience  or  feeling  it  causes."  The  misuse  of  over- 
the-counter  medications  also  constitutes  risky  use; 
however,  rates  of  risky  use  in  this  report  do  not 
include  the  misuse  of  these  medications  since  they 
are  not  directly  measured  in  the  national  surveys  that 
were  analyzed  for  this  study. 

Substances  controlled  (either  through  prohibited  or 
restricted  use)  through  the  federal  Controlled 
Substances  Act  of  1970,  which  created  a  system  for 
classifying  illicit  and  prescription  drugs  according  to 
their  medical  value  and  their  potential  for  misuse.  In 
this  analysis,  illicit  drugs  include  marijuana/hashish, 
cocaine/crack,  heroin,  hallucinogens,  Ecstasy, 
methamphetamine  and  inhalants. 


-5- 


To  document  the  research  on  the  causes, 
consequences  and  extent  of  risky  substance  use 
and  addiction;  the  available  tools  for  effective 
interventions  and  for  treatment;  the  gap  between 
the  need  for  such  interventions  and  treatments 
and  the  actual  standard  of  care;  the  driving 
forces  behind  this  substantial  gap;  and  to 
develop  concrete  recommendations  for 
minimizing  it,  CASA  Columbia  conducted:* 

•  A  thorough  review  of  more  than  7,000 
scientific  articles,  reports,  books  and  other 
reference  materials  related  to  the  science  of 
addiction,  the  consequences  of  risky  use  and 
addiction,  the  prevention  of  risky  use  and 
treatment  of  addiction  and  barriers  to 
improved  care  (see  Appendix  A); 

•  Secondary  analysis  of  five  national  data  sets 
(see  Appendix  A); 

•  Interviews  with  and  suggestions  from  176 
leading  experts  in  a  broad  range  of  fields 
relevant  to  the  report,  including  researchers, 
physicians  and  other  health  professionals, 
other  treatment  providers,  policymakers  and 
members  of  professional  associations, 
advocacy  organizations,  health  insurers, 
pharmaceutical  companies  and  organizations 
of  people  with  the  disease  of  addiction. 
Whereas  the  majority  of  these  experts 
provided  their  thoughts  in  the  context  of  an 
open-ended  interview  guide  designed  by 
CASA  Columbia  to  explore  key  themes 
related  to  this  project,  some  provided  advice, 
suggestions  and  feedback  about  specific 
content  to  be  included  in  this  report  (see 
Appendices  A  and  B); 

•  Focus  groups  and  a  national  general 
population  survey  assessing  the  attitudes  and 
beliefs  of  1,303  adults  with  regard  to 
addiction  and  its  treatment:  the  National 
Addiction  Belief  and  Attitude  Survey 
(NABAS)  (see  Appendices  A  and  C); 

•  Two  statewide  surveys  of  addiction 
treatment  providers  in  New  York:  one  of  83 


program  directors  and  one  of  141  staff 
treatment  providers  (see  Appendices  A,  D 
and  E); 

•  A  national  panel  of  treatment  providers  and 
an  online  survey  of  1,142  members  of 
professional  associations  involved  in 
addiction  care  (see  Appendices  A  and  F); 

•  An  online  survey  of  360  individuals  with  a 
history  of  addiction  who  are  managing  the 
disease  (see  Appendices  A  and  G); 

•  An  in-depth  analysis  of  state  and  federal 
governments'  and  professional  associations' 
licensing  and  certification  requirements  for 
individual  treatment  providers  and  addiction 
treatment  facilities  and  programs,  as  well  as 
accreditation  requirements  for  facilities  and 
programs  (see  Appendix  A);  and 

•  A  case  study  of  addiction  treatment  in  New 
York  State  and  New  York  City  that  drew 
from  the  research  described  above  and  the 
findings  of  which  are  incorporated  into  the 
report  where  relevant  (see  Appendix  A). 

Key  Findings 

Addiction  Is  a  Brain  Disease 

Addiction  is  a  complex  brain  disease  with 
significant  behavioral  characteristics.23 
Nicotine,  alcohol,  illicit  drugs  and  controlled 
prescription  drugs  all  affect  the  pleasure  and 
reward  circuitry  of  the  brain  in  similar  ways.24 
Over  time,  continued  use  of  these  substances  can 
physically  alter  the  structure  and  function  of  the 
brain,  dramatically  affect  judgment  and 
behavior25  and  drive  a  compulsion  to  obtain  and 
use  them,  even  in  the  face  of  mounting  negative 
consequences.26  Growing  evidence  also  points 
to  structural  and  functional  differences  in  the 
brain  and  to  genetic  factors  that  may  predispose 
certain  individuals  to  addiction.27 


See  Appendix  A  for  a  more  detailed  description  of 
the  key  methodological  components  of  the  study. 


-6- 


As  with  Other  Health  Conditions,  There 
Are  Clear  Risk  Factors  for  the 
Development  of  Addiction 

Risk  factors  for  developing  addiction  include  a 
genetic  predisposition,  structural  and  functional 
brain  vulnerabilities,  psychological  factors  and 
environmental  influences.  Whereas  biological, 
psychological  and  environmental  factors— such 
as  impairments  in  the  brain's  reward  circuitry, 
compensation  for  trauma  and  mental  health 
problems,  easy  access  to  addictive  substances, 
substance  use  in  the  family  or  media  and  peer 
influences— play  a  large  role  in  whether  an 
individual  starts  to  smoke,  drink,  or  use  other 
drugs,28  genetic  factors  are  more  influential  in 
determining  who  develops  the  disease  of 
addiction.29  A  factor  that  is  particularly 
predictive  of  risk,  however,  is  the  age  of  first 
use;  in  96.5  percent  of  cases,  addiction 
originates  with  substance  use  before  the  age  of 
2 1 30  when  the  brain  is  still  developing  and  is 
more  vulnerable  to  the  effects  of  addictive 
substances.* 31 

Addiction  Frequently  Co-Occurs  with 
Other  Health  Conditions 

Addiction  frequently  co-occurs  with,  contributes 
to  or  causes  a  wide  range  of  medical  conditions. 
Both  risky  substance  use  and  addiction  cause  or 
contribute  to  more  than  70  other  conditions 
requiring  medical  care,  such  as  heart  disease  and 
cancer,32  as  well  as  mental  health  and  behavioral 
disorders-including  depression,  anxiety,  post- 
traumatic stress  disorder,  bipolar  disorder, 
schizophrenia  and  other  neuropsychiatric 
disorders.33 

Addiction  Can  Be  a  Chronic  Disease 

There  is  tremendous  variation  in  the  severity  and 
course  of  the  disease  of  addiction  and  of  its 
symptoms.  Some  individuals  may  experience 
one  episode  in  which  their  symptoms  meet 
clinical  diagnostic  criteria  for  addiction  and  be 
non- symptomatic  thereafter.34  In  many  cases, 


These  individuals  also  might  have  a  predisposition 
to  develop  addiction,  irrespective  of  their  actual  use 
of  addictive  substances. 


however,  addiction  manifests  as  a  chronic 
disease-a  persistent  or  long-lasting  illness— 
which  requires  ongoing  professional  treatment 
and  management.35  However,  very  few  people 
with  addiction  actually  receive  adequate, 
effective,  evidence-based  treatment,36  and  the 
usual  approach  to  treatment  involves  brief, 
episodic  interventions  rather  than  a  model  based 
on  long-term  chronic  disease  management.  As  a 
result,  high  rates  of  relapse,  while  comparable  to 
other  chronic  diseases,  may  be  due  at  least  in 
part  to  inadequate  or  ineffective  interventions 
and  treatments.37 

A  Lack  of  Standardized  Terminology 
Compromises  Effective  Interventions 

Terms  used  to  describe  different  levels  of 
involvement  with  addictive  substances— such  as 
experimentation,  use,  misuse,  excessive  use, 
abuse,  dependence  and  addiction—lack 
precision,  obscuring  important  differences  in  the 
nature  and  severity  of  the  illness  and 
complicating  our  ability  to  intervene  and  treat  it 
effectively.  Even  the  word  "treatment"  lacks 
precision  with  regard  to  addiction,  since 
historically  it  has  been  used  to  refer  to  a  host  of 
interventions,  many  of  which  are  not  based  in 
the  clinical  and  scientific  evidence  as  are 
treatments  for  other  diseases. 

Multiple  Addictive  Substances  and 
Behaviors  Frequently  Are  Involved  in 
Risky  Use  and  Addiction 

Traditionally,  risky  substance  use  and  addiction 
have  been  addressed  largely  on  a  substance- 
specific  basis.  Growing  understanding  of  the 
nature  of  risky  use  and  the  disease  of  addiction- 
including  the  risk  factors,  symptoms  and  the 
neuropsychological  effects  of  addictive 
substances-helps  to  explain  the  significant 
proportion  of  risky  users  and  those  who  are 
addicted  who  are  involved  with  more  than  one 
addictive  substance.  Among  risky  substance 
users  who  do  not  meet  diagnostic  criteria  for 
addiction,  30.6  percent  are  risky  users  of  more 
than  one  substance.  Among  those  who  are 
addicted,  55.7  percent  are  risky  users  of  one  or 


-7- 


more  other  substances  and  17.3  percent  have 
addiction  involving  multiple  substances.38 

Emerging  research  also  suggests  that  other 
behavioral  manifestations  of  addiction  (e.g., 
obesity,  gambling,  sexual  addiction)  share 
common  neuropsychological  and  genetic 
pathways  with  addiction  involving  substances,39 
underscoring  the  importance  of  treating  the 
antecedents,  manifestations  and  consequences  of 
addiction  more  generally.  When  treatments  are 
too  highly  focused  on  a  specific  addictive 
substance  or  behavior,  they  may  not  be 
addressing  the  actual  underlying  disease  of 
addiction  or  the  possibility  of  addiction 
substitution,  where  a  patient  may  replace  one 
form  of  addiction  with  another.40 

Public  Attitudes  about  the  Causes  of 
Addiction  Are  Out  of  Sync  with  the  Science 

CASA  Columbia's  national  survey  of  the 
attitudes  and  beliefs  of  adults  in  the  U.S.  with 
regard  to  addiction  and  its  treatment  (the 
NABAS)  found  that  while  there  is  public 
recognition  of  the  role  of  genetics  and  biological 
factors  in  the  development  of  addiction, 
approximately  one-third  of  Americans  continue 
to  view  addiction  as  a  sign  of  lack  of  will  power 
or  self-control.41 

Physicians  and  Other  Health  Professionals 
Should  Be  on  the  Front  Line  Addressing 
this  Disease 

As  with  other  diseases,  addiction  should  be 
addressed  within  the  medical  system  by 
physicians  (including  multiple  medical 
specialties  and  sub-specialties)  and  a  multi- 
disciplinary  team  of  health  professionals 
including  physician  assistants,  nurses  and  nurse 
practitioners,  and  graduate  level  clinical 
psychologists,  social  workers  and  counselors. 

In  order  to  treat  addiction  and  reduce  risky 
substance  use  and  the  related  consequences, 
physicians  and  other  health  professionals  must: 

•    Understand  the  risk  factors,  how  these  risks 
vary  across  the  lifespan,  how  risky 


substance  use  that  does  not  result  in 
addiction  has  far-reaching  adverse 
consequences  and  that  addiction  frequently 
co-occurs  with  other  health  conditions; 

•  Educate  patients,  and  their  families  if 
relevant,  about  these  risks,  the  nature  of  the 
disease  of  addiction  and  the  adverse 
consequences  of  risky  substance  use; 

•  Screen  for  risky  substance  use  and 
symptoms  of  addiction  and  co-occurring 
health  conditions  using  tools  that  have  been 
proven  to  be  effective; 

•  Provide  brief  interventions  when 
appropriate;  and 

•  Treat  and  manage  the  disease  or  provide 
referrals  to  specialty  care  if  needed. 

Non-laboratory-based  screening  for  risky 
substance  use  can  be  conducted  by  a  wide  range 
of  trained  health  professionals  and  brief 
interventions  can  be  conducted  by  physicians 
and  by  appropriately  trained  clinicians, 
supervised  as  necessary.  All  aspects  of 
stabilization  and  treatment— including 
laboratory-based  screening,  assessment,  acute 
care  and  disease  management-should  be 
managed  by  a  physician,  as  is  the  case  with 
other  medical  illnesses.  Highly-trained  clinical 
mental  health  professionals  can  provide 
psychosocial  therapies  as  part  of  a  treatment 
plan  established  and  managed  by  the  patient's 
physician.  Case  management  can  be  provided 
by  nurses  and  nurse  practitioners,  physician 
assistants  and  clinical  mental  health 
professionals  if  appropriately  trained  in 
addiction  and  if  the  services  are  performed  under 
the  supervision  of  a  physician.  Paraprofessionals 
and  non-clinically  trained  and  credentialed 
counselors  can  provide  auxiliary  services  as  part 
of  a  comprehensive  treatment  and  disease 
management  plan. 


-8- 


Referrals  to  specialty  addiction  care  should  be 
made  to  trained  and  credentialed  addiction 
physician  specialists.*  42 

Screening  and  Intervention  Are  Effective 
at  Addressing  Risky  Substance  Use  and 
Forestalling  Addiction 

Screening  and  brief  interventions  have  been 
found  to  be  effective  tools  for  addressing  the 
risky  use  of  tobacco,43  alcohol,44  illicit  drugs  and 
controlled  prescription  drugs45  in  multiple 
settings  and  in  many  population  groups  46 

A  range  of  screening  tools  exist  and  typically 
include  written  or  oral  questionnaires  and,  less 
frequently,  clinical  and  laboratory  tests. 
However,  most  screening  tools  are  substance 
specific;  an  instrument  that  screens  for  risky  use 
or  addiction  involving  all  substances  as  a  unified 
dimension-and  that  makes  appropriate 
distinctions  for  age,  culture  and  gender-has  yet 
to  be  developed. 

For  those  who  screen  positive  for  risky 
substance  use  that  does  not  meet  the  threshold  of 
clinical  addiction,  a  brief  intervention-typically 
involving  motivational  interviewing  techniques 
and  substance-related  education—is  an  effective, 
low-cost  approach  to  reducing  risky  substance 
use.47 

Effective  Therapies  to  Treat  and  Manage 
Addiction  Exist 

For  individuals  showing  signs  of  addiction,  a 
comprehensive  assessment  of  the  stage  and 
severity  of  the  disease  and  the  provision  of 
treatment  and  disease  management  are  critical  to 
improving  health  and  preventing  further  health 
and  social  consequences.48  As  is  true  of  other 
chronic  diseases,  while  all  patients  with 


There  are  two  major  categories  of  addiction 
physician  specialists:  physician  experts  in  addiction 
medicine— Diplomates  of  the  American  Board  of 
Addiction  Medicine  (ABAM)-and  physician  experts 
in  addiction  psychiatry  (psychiatrists  with  sub- 
specialty certification  in  addiction  psychiatry)— 
Diplomates  of  the  American  Board  of  Psychiatry  and 
Neurology  (ABPN). 


addiction  will  not  respond  equally  well  to 
treatment,  the  provision  of  evidence-based 
treatment  does  increase  the  odds  of  success. 

Addiction  is  a  disease  that  can  be  treated  and 
managed  effectively  within  the  medical 
profession  using  an  array  of  evidence-based 
pharmaceutical  and  psychosocial  approaches.  In 
accordance  with  standard  medical  practice  for 
the  treatment  of  other  chronic  diseases,  best 
practices  for  the  effective  treatment  and 
management  of  addiction  must  be  consistent 
with  the  scientific  evidence  of  the  causes  and 
course  of  the  disease.  Best  practices  require:49 

•  Comprehensive  assessment  of  the  extent 
and  severity  of  the  disease,  determination  of 
a  clinical  diagnosis,  evaluation  of  co- 
occurring  health  conditions  and  the 
development  of  a  tailored  treatment  plan; 

•  Stabilization  of  the  patient's  condition  via 
cessation  of  substance  use  and  medically 
supervised  detoxification,  when  necessary, 
as  a  precursor  to  treatment; 

•  Acute  Care  delivered  by  qualified  health 
care  professionals  via  evidence-based 
pharmaceutical  and/or  psychosocial 
addiction  treatments,  accompanied  by 
treatment  for  co-occurring  health  conditions; 

•  Chronic  Disease  Management  to  help  the 
patient  maintain  the  progress  achieved 
during  acute  treatment  and  prevent  relapse. 
The  process  should  be  medically  supervised 
and  should  involve  pharmaceutical  and/or 
psychosocial  therapies  and  continued 
management  of  co-occurring  health 
conditions  as  indicated;  and 

•  Support  Services  including  the  provision  of 
auxiliary  services  such  as  legal,  educational, 
employment,  housing  and  family  supports, 
as  well  as  nutrition  and  exercise  counseling 
and  connection  to  mutual  support  programs. 


-9- 


The  Importance  of  Tailored  Interventions 
and  Treatment 

Each  life  phase  presents  unique  vulnerabilities 
for  risky  substance  use  and  the  onset  of  the 
disease  of  addiction.  Recognizing  these 
differences  as  well  as  the  basic  risk  factors  for 
each  is  critical  to  reducing  risky  substance  use 
and  addiction. 

Certain  populations-such  as  pregnant  women,50 
the  young51  and  the  elderly52— are  more 
vulnerable  to  the  damaging  and  addictive  effects 
of  tobacco,  alcohol  and  other  drugs.  Among 
members  of  the  military  exposed  to  combat,53 
persons  with  co-occurring  health  conditions54 
and  individuals  involved  in  the  justice  system55 
the  likelihood  of  addiction  is  significantly  higher 
than  in  the  general  population. 

Treatment  must  be  tailored  to  the  particular 
stage  and  severity  of  the  disease,  a  patient's 
overall  health  status,  past  treatments  and  any 
other  personal  characteristics  and  life 
circumstances  that  might  affect  patient 
outcomes.56  These  include  patients  with  co- 
occurring  health  conditions,  adolescents, 
women,  older  adults,  racial  and  ethnic 
minorities,  individuals  of  minority  sexual 
orientation,  veterans  and  individuals  involved  in 
the  justice  system.  The  research  evidence 
clearly  demonstrates  that  a  one-size-fits-all 
approach  to  addiction  treatment  typically  is  a 
recipe  for  failure.57 

Public  Attitudes  about  Addiction  Treatment 
Reflect  the  Prevailing  Non-Medical 
Approach  to  Addiction  Care 

CAS  A  Columbia's  NAB  AS  found  that  although 
the  American  public  appears  to  be  supportive  of 
assuring  that  individuals  with  addiction  receive 
effective  addiction  treatment,  public  views  about 
what  constitutes  addiction  treatment  do  not 
comport  with  the  science:  more  than  half  (60. 1 
percent)  of  respondents  to  the  NABAS 
spontaneously  offered  mutual  support  programs 
such  as  AA  or  NA  as  a  "treatment"  intervention 
when  asked  what  kinds  of  treatment  come  to 
mind  when  they  think  about  treatment  for 


addiction,    despite  the  fact  that  such  programs, 
while  very  helpful  sources  of  support  to  many 
individuals  with  addiction,  are  not  evidence- 
based  treatments  for  the  disease.59  The  public 
also  does  not  seem  to  distinguish  between  risky 
substance  use  and  the  disease  of  addiction. 

Most  People  in  Need  of  Treatment  Do  Not 
Receive  It 

As  an  indicator  of  the  lack  of  attention  afforded 
the  disease  of  addiction,  no  single  national  data 
source  exists  to  compare  the  proportion  of  the 
population  in  need  of  addiction  treatment 
involving  any  addictive  substance  to  the 
proportion  that  receives  such  treatment.  While 
about  seven  out  of  1 0  people  with  hypertension, 
major  depression  or  diabetes  get  treatment  for 
their  medical  conditions,  only  about  one  in  1 0 
people  with  addiction  involving  alcohol  or  drugs 
other  than  nicotine  do,* 60  (Figure  l.B),  leaving  a 
treatment  gap  of  20.7  million  individuals.61 
No  data  exist  on  the  treatment  gap  for  those  with 
addiction  involving  nicotine.  The  proportion  of 
individuals  in  need  of  addiction  treatment 
involving  alcohol  and  drugs  other  than  nicotine 
who  actually  receive  it  has  changed  little  since 
2002,  when  9.8  percent  of  those  in  need  received 
treatment.62 


For  this  comparison,  CASA  Columbia  examined  the 
referenced  national  survey  data  to  determine  the 
proportion  of  the  population  with  each  disease-those 
with  diagnosed  or  undiagnosed  hypertension  (59.3 
million);  those  with  diagnosed  or  undiagnosed 
diabetes  (25.8  million);  those  who  met  clinical 
criteria  for  a  major  depressive  episode  in  the  past 
year  and/or  received  professional  treatment  (saw  a 
doctor,  received  medication,  a  combination  thereof) 
(22.4  million);  and  those  who  met  clinical  criteria  for 
addiction  involving  alcohol  or  other  drugs  excluding 
nicotine  in  the  past  year  and/or  received  professional 
treatment  for  alcohol  and/or  other  drugs  in  the  past 
year  (23.2  million)-who  received  treatment. 


-10- 


Most  Referrals  to  Publicly  Funded 
Treatment  Come  from  the  Criminal  Justice 
System 

CASA  Columbia's  national  survey  conducted 
for  this  study  found  that  46.8  percent  of 
respondents  would  turn  to  a  health  professional- 
such  as  their  physician  (27.8  percent),  a  health 
professional  other  than  their  primary  care 
physician  (19.7  percent)  or  a  mental  health 
professional  (9.2  percent)  —if  someone  close  to 
them  needed  help  for  addiction.63  However, 
only  5.7  percent  of  referrals  to  publicly  funded 
treatment  came  from  a  health  care  provider.  In 
contrast,  a  full  44.3  percent  of  the  referrals  to 
treatment  were  from  the  criminal  justice 
system,64  highlighting  the  fact  that  this  disease 
typically  is  addressed  only  at  the  point  at  which 
it  results  in  profound  social  consequences. 

One-quarter  (25.3  percent)  of  referrals  came 
from  individuals,  including  concerned  family 
members,  friends  and  the  self-referred;  12.1 
percent  were  referred  by  community  sources 
such  as  social  welfare  organizations,  religious 
organizations  and  mutual  support  programs;  and 
10.6  percent  were  referred  by  addiction 
treatment  providers  for  additional  treatment. 
Very  few  treatment  referrals  came  from  schools 
(1.4  percent)  or  from  employers  (0.6  percent).65 
(Figure  l.C) 


Figure  1  .B 

Individuals  with  Select  Medical  Conditions 
Who  Receive  Treatment 


Hypertension1 


Diabetes2 


Major 
Depression3 


Addiction3 
(excluding 
Nicotine*) 


1  Ages  18  and  older;  Ostchega,  Y.,  Yoon,  S.S.,  Hughes,  J.  &  Louis,  T. 
(2008). 

2  All  ages;  Centers  for  Disease  Control  and  Prevention.  (201 1). 

3  Ages  1 2  and  older;  CASA  Columbia  analysis  of  The  National  Survey 
on  Drug  Use  and  Health  (NSDUH),  201 0 

*  Due  to  data  limitations. 


Figure  1.C 

Sources  of  Referral  to  Publicly-Funded 
Addiction*  Treatment 


Criminal  Justice  System 
Individuals 
Community  Sources 
Addiction  Treatment  Providers 
Health  Care  Providers 
Schools 


*  Excluding  nicotine. 

Source:  CASA  Columbia  analysis  of  The  Treatment  Episode 
Data  Set  (TEDS),  2009. 


Some  respondents  chose  more  than  one  response,  so 
the  46.8  percent  reflects  those  who  chose  either  one 
of  these  health  professionals. 


-11- 


Less  than  Half  of  Treatment  Admissions 
Result  in  Treatment  Completion 

In  2008,*  less  than  half  (42.1  percent)  of 
discharges  from  formal  addiction  treatment 
services  were  of  admissions  in  which  treatment 
was  completed.66  The  highest  completion  rates 
were  from  venues  to  which  there  were  the 
fewest  admissions: 

•  14.8  percent  of  admissions  were  to  short- 
term  residential  services  which  had  the 
highest  completion  rate  of  54.8  percent; 

•  11.4  percent  of  admissions  were  to  longer- 
term  residential  treatment  which  had  a 
completion  rate  of  45.5  percent;  and 

•  73.8  percent  of  admissions  were  to  non- 
residential services  which  had  the  lowest 
completion  rate  of  39.1  percent.67 

No  data  are  available  on  the  extent  to  which 
referrals  were  based  on  matching  providers  with 
individual  treatment  needs. 

Patients  Face  Formidable  Barriers  to 
Receiving  Addiction  Treatment 

In  addition  to  the  lack  of  treatment  referrals 
from  the  health  care  system,  many  other  barriers 
stand  in  the  way  of  individuals  accessing  and 
completing  addiction  treatment.  These  include: 
a  misunderstanding  of  the  disease,  negative 
public  attitudes  and  behavior  toward  those  with 
the  disease,  privacy  concerns,  insufficient 
insurance  coverage  of  the  costs  of  treatment, 
lack  of  information  on  how  to  get  help,  limited 
availability  of  services  including  a  lack  of 
addiction  physician  specialists,  insufficient 
social  support,  conflicting  time  commitments, 
negative  perceptions  of  the  treatment  process 
and  legal  barriers.  Rarely  is  there  only  one 
obstacle  to  a  person  receiving  needed 
treatment.68  Although  comparable  national  data 
for  barriers  to  accessing  smoking  cessation 
treatment  are  not  available,  research  indicates 
that  barriers  similar  to  those  facing  individuals 


Most  recent  available  data  on  discharges. 


seeking  treatment  for  addiction  involving 
alcohol  or  other  drugs  stand  in  the  way  of 
smokers  accessing  tobacco  cessation  services.69 

The  Spending  Gap 

In  2010,  the  United  States  spent  $43.8  billion  to 
treat  diabetes70  which  affects  25.8  million 
people,71  $86.6  billion  to  treat  cancer72  which 
affects  19.4  million  people73  and  an  estimated 
$107.0  billion  to  treat  heart  conditions74  which 
affect  27.0  million  people,75  but  only  $28.0 
billion  to  treat  addiction  which  affects  40.3 
million  people.1 76  Looking  just  at  government 
spending,  CASA  Columbia  calculated  that  in 
2005,  risky  substance  use-  and  addiction-related 
spending  accounted  for  10.7  percent  of  federal, 
state  and  local  spending,  and  that  for  every 
dollar  federal  and  state  governments  spent,  95.6 
cents  went  to  pay  for  the  consequences  of 
substance  use;  only  1.9  cents  was  spent  on  any 
type  of  prevention  or  treatment/  The  taxpayer 
tab  for  government  spending  on  the 
consequences  of  risky  substance  use  and 
addiction  alone  totals  almost  $1,500  a  year  for 


1  There  are  no  national  data  that  document  spending 
on  treatment  for  addiction  involving  nicotine; 
although  the  cost  estimate  of  $28.0  billion  applies  to 
the  treatment  of  addiction  involving  alcohol  or  other 
drugs  excluding  nicotine,  the  prevalence  estimate  of 
those  with  addiction  (40.3  million)  includes  those 
with  addiction  involving  nicotine. 
*  Due  to  data  limitations,  the  prevalence  estimates  for 
cancer  and  heart  conditions  include  individuals  ages 
18  and  older  who  have  ever  been  told  by  a  doctor  or 
other  health  professional  that  they  have  the  condition 
(cancer/malignancy  or  a  heart  condition).  The 
prevalence  estimate  for  diabetes  includes  all  ages  and 
the  estimate  for  addiction  includes  individuals  ages 
12  and  older;  for  diabetes  and  addiction,  the 
prevalence  estimates  include  both  diagnosed  and 
undiagnosed  cases.  In  each  case,  total  costs  of 
treatment  are  included  without  regard  to  age.  The 
cost  estimates  for  treating  diabetes,  cancer  and  heart 
conditions  were  inflated  to  2010  dollars  using  the 
medical  inflation  factor  (7.9  percent)  found  in 
SAMHSA's  National  Expenditures  for  Mental 
Health  Services  and  Substance  Abuse  Treatment, 
1986-2005  publication. 

§  In  addition,  0.4  cents  was  spent  on  research,  1.4 
cents  on  taxation  or  regulation  and  0.7  cents  on 
interdiction. 


-12- 


every  person  in  America.    Nearly  one-third 
(32.3  percent)  of  all  hospital  inpatient  costs  are 
attributable  to  substance  use  and  addiction.78 

Most  Funding  for  Addiction  Treatment 
Comes  from  Public  Sources 

Spending  on  addiction  treatment  totaled  an 
estimated  $28.0  billion  in  2010.  Whereas 
private  payers  (including  private  insurers  and 
self-payers)  are  responsible  for  55.6  percent 
($  1 .4  trillion)  of  medical  expenditures  in  the 
U.S.,  they  are  responsible  for  only  20.8  percent 
($5.8  billion)  of  addiction  treatment  spending.79 

The  concentration  of  spending  for  addiction 
treatment  in  public  programs  suggests  that 
insurance  across  the  board  does  not  adequately 
cover  costs  of  intervention  and  treatment, 
resulting  in  costly  health  and  social 
consequences  that  stem  from  untreated  addiction 
and  that  fall  disproportionately  to  government 
programs.  National  data  indicate  that 
individuals  with  private  insurance  are  three  to 
six  times  less  likely  than  those  with  public 
insurance  to  receive  specialty  addiction 
treatment.80 

The  Education,  Training  and 
Accountability  Gap 

Compounding  the  profound  gap  between  the 
need  for  addiction  treatment  and  the  receipt  of 
such  care  is  the  enormous  gulf  between  the 
knowledge  available  about  addiction  and  its 
prevention  and  treatment  and  the  education  and 
training  received  by  those  who  provide  or  should 
provide  care.  In  spite  of  the  evidence  that 
addiction  is  a  disease: 

•  Most  medical  professionals  who  should  be 
providing  addiction  treatment  are  not 
sufficiently  trained  to  diagnose  or  treat  it; 

•  Most  of  those  who  are  providing  addiction 
treatment  are  not  medical  professionals  and 
are  not  equipped  with  the  knowledge,  skills 
or  credentials  necessary  to  provide  the  full 
range  of  evidence-based  services  to  address 
addiction  effectively;81  and 


•    Addiction  treatment  facilities  and  programs 
are  not  adequately  regulated  or  held 
accountable  for  providing  treatment 
consistent  with  medical  standards  and 

82 

proven  treatment  practices. 

Further  complicating  this  education,  training  and 
accountability  gap  is  the  fact  that  there  are  no 
national  standards  for  the  provision  of  addiction 
treatment  and  instead  considerable  inconsistency 
among  states  in  the  regulation  of  individual 
treatment  providers  and  of  the  programs  and 
facilities  that  provide  addiction  treatment 
services.* 

The  Profound  Disconnect  between 
Evidence  and  Practice 

The  prevention  and  reduction  of  risky  substance 
use  and  the  treatment  of  addiction,  in  practice, 
bear  little  resemblance  to  the  significant  body  of 
evidence-based  practices  that  have  been 
developed  and  tested;  indeed  only  a  small 
fraction  of  individuals  receive  interventions  or 
treatment  consistent  with  scientific  knowledge 
about  what  works.83 

Providing  quality  care  to  identify  and  reduce 
risky  substance  use  and  diagnose,  treat  and 
manage  addiction  requires  a  critical  shift  to 
science-based  interventions  and  treatment  by 
health  care  professionals— both  primary  care 
providers  and  specialists. 

Significant  barriers  stand  in  the  way  of  making 
this  critical  shift,  including:  an  addiction 
treatment  workforce  starved  of  resources, 
operating  outside  the  medical  profession  and 
lacking  capacity  to  provide  the  full  range  of 
evidence-based  practices  including  necessary 
medical  care;  a  health  professional  that  should 
be  responsible  for  providing  addiction  screening, 
interventions,  treatment  and  management  but 
does  not  implement  evidence-based  addiction 
care  practices;  inadequate  oversight  and  quality 
assurance  of  treatment  providers  and 
intervention  practices;  limited  advances  in  the 


With  the  notable  exception  of  the  regulation  of 
medication-assisted  therapy  for  addiction  involving 
opioids. 


-13- 


development  of  pharmaceutical  treatments  and 
the  adoption  of  existing  pharmaceutical 
therapies;  and  a  lack  of  adequate  insurance 
coverage. 

Recent  efforts  by  government  agencies  and 
professional  associations  have  begun  to  tackle 
these  challenges  to  closing  the  evidence-practice 
gap,  but  are  simply  insufficient. 

Nothing  short  of  a  significant  overhaul  in  current 
approaches  is  required  to  bring  practice  in  line 
with  the  evidence  and  with  the  standard  of  care 
for  other  public  health  and  medical  conditions. 
Given  the  prevalence  of  risky  substance  use  and 
addiction  in  America  and  the  extensive  evidence 
on  how  to  identify  and  address  them,  continued 
failure  to  do  so  raises  the  question  of  whether 
the  insufficient  care  that  patients  with  addiction 
usually  do  receive  constitutes  a  form  of  medical 
malpractice.  It  also  signals  widespread  system 
failure  in  health  care  service  delivery,  financing, 
professional  education  and  quality  assurance. 

Recommendations  and  Next  Steps 

It  is  time  for  health  care  practice  to  catch  up 
with  the  science.  There  is  no  silver  bullet  to 
making  this  happen;  instead,  a  broad  set  of 
comprehensive  reforms  must  be  put  in  place. 
Toward  this  end,  CASA  Columbia  makes  the 
following  recommendations: 

Reform  Health  Care  Practice 

•    Incorporate  screening  and  intervention 
for  risky  substance  use,  and  diagnosis, 
treatment  and  disease  management  for 
addiction  into  routine  medical  practice. 

As  essential  components  of  routine  medical 
care,  all  physicians  and  other  medical 
professionals  should  provide  their  patients 
with  addiction-related  screening  and,  as 
needed:  brief  interventions;  comprehensive 
assessment  to  determine  disease  stage, 
severity  and  the  presence  of  co-occurring 
health  conditions;  stabilization;  acute 
treatment;  chronic  disease  management;  and 
connection  to  support  and  auxiliary  services. 
Patients  with  severe  cases  of  addiction 


should  be  referred  to  an  addiction  physician 
specialist. 

•  All  medical  schools  and  residency 
training  programs  should  educate  and 
train  physicians  to  address  risky 
substance  use  and  addiction.  All 

physicians  should  be  educated  and  trained  in 
the  origins  of  risky  substance  use  and 
addiction;  prevention,  intervention, 
treatment  and  management  options;  co- 
occurring  conditions;  and  special  population 
and  specialty-care  needs.  These  core 
clinical  competencies  should  be  required 
components  of  all  medical  school  curricula, 
medical  residency  training  programs, 
medical  licensing  exams,  board  certification 
exams  and  continuing  medical  education 
(CME)  requirements,  including  maintenance 
of  certification  programs. 

•  Require  non-physician  health 
professionals  to  be  educated  and  trained 
to  address  risky  substance  use  and 
addiction.  Develop  core  clinical 
competencies  in  addressing  risky  use  and 
preventing  and  treating  addiction  for  each 
type  of  non-physician  health  professional 
including,  physician  assistants,  nurses  and 
nurse  practitioners,  dentists,  pharmacists  and 
graduate-level  clinical  mental  health 
professionals  (psychologists,  social  workers, 
counselors).  Assure  that  these  core  clinical 
competencies  and  specialized  training  are 
required  components  of  all  professional 
health  care  program  curricula,  graduate 
fellowship  training  programs,  professional 
licensing  exams  and  continuing  education 
(CE)  requirements.  Require  all  non- 
physician  health  professionals  providing 
psychosocial  addiction  treatment  services  to 
have  graduate- level  clinical  training  in 
delivering  these  services.  Require  that  all 
pharmaceutical  treatments  for  addiction  be 
provided  only  by  a  physician  or  in 
accordance  with  a  treatment  plan  managed 
by  a  physician. 

•  Develop  improved  screening  and 
assessment  instruments.  Screening 
instruments  should  be  adjusted  or  developed 


-14- 


to  coincide  with  appropriate  definitions  of 
risky  substance  use,  and  assessment 
instruments  should  be  adjusted  or  developed 
to  mirror  diagnostic  criteria  for  addiction. 
Both  screening  and  assessment  instruments 
should  address  all  types  of  addictive 
substances. 

•  Establish  national  accreditation 
standards  for  all  addiction  treatment 
facilities  and  programs  that  reflect 
evidence-based  care.  As  a  condition  of 
accreditation,  accrediting  organizations 
should  stipulate  requirements  for  all 
facilities  and  programs  providing  addiction 
treatment  with  regard  to  professional 
staffing  (e.g.,  requiring  them  to  have  a  full- 
time  certified  addiction  physician  specialist 
on  staff  to  serve  as  medical  director,  oversee 
patient  care  and  be  responsible  for  all 
treatment  services),  intervention  and 
treatment  services  (e.g.,  requiring  them  to 
provide  comprehensive  assessment  and 
evidence-based  treatment  for  addiction 
involving  all  substances  that  is  tailored  to 
the  stage  and  severity  of  the  disease,  co- 
occurring  conditions  and  patient 
characteristics),  and  quality  assurance  (e.g., 
requiring  them  to  collect  and  report 
comprehensive  quality  assessment  data, 
including  process  and  outcome 
measurements). 

•  Standardize  language  used  to  describe  the 
full  spectrum  of  substance  use  and 
addiction.  Recognize  addiction  as  a 
primary  medical  disease  and  standardize  the 
language  related  to  the  spectrum  of 
substance  use  severity  in  current  and 
forthcoming  diagnostic  instruments. 
Develop  a  classification  system  based  both 
on  observable  behavior  and  neurobiological 
measures  that  underlie  different 
manifestations  of  addiction  and  related 
conditions  which  currently  are  classified  and 
addressed  as  distinct  conditions. 


Use  the  Leverage  of  Public  Policy  to  Speed 
Reform  in  Health  Care  Practice 

•  Condition  grants  and  contracts  for 
addiction  services  on  the  provision  of 
quality  care.  Federal,  state  and  local 
governments  should  require-as  a  condition 
of  receipt  of  public  funds-that  grants, 
contracts  and  non-insurance  reimbursement 
for  addiction  treatment  services  utilize 
evidence-based  prevention  and  treatment 
approaches,  including  pharmaceutical 
therapies  (provided  or  managed  by  a 
physician  demonstrating  the  core 
competencies  of  addiction  medicine  or 
addiction  psychiatry)  and  psychosocial 
therapies  (provided  by  medical  professionals 
or  graduate-level  clinical  mental  health 
professionals  trained  and  licensed  in  the  core 
competencies  of  addiction  treatment),  as 
indicated;  involve  other  health  professionals, 
individuals  providing  auxiliary  services  and 
those  providing  peer  support,  working  in  a 
multidisciplinary  team;  and  generate 
positive  and  measurable  long-term  patient 
outcomes. 

•  Educate  non-health  professionals  about 
risky  substance  use  and  addiction. 

Require  that  the  topic  of  risky  substance  use 
and  addiction  be  included  in  the  education 
and  training  of  government- funded 
professionals  who  do  not  provide  direct 
addiction-related  services  but  who  come  into 
contact  with  significant  numbers  of 
individuals  who  engage  in  risky  substance 
use  or  who  may  have  addiction.  These 
include,  but  are  not  limited  to  law 
enforcement  and  other  criminal  justice 
personnel,  legal  staff,  child  welfare  and 
other  social  service  workers  and  educators. 

•  Identify  patients  at  risk  in  government 
programs  and  services  where  costs  of 
risky  use  and  addiction  are  high.  Federal, 
state  and  local  governments  should  require 
that  routine  screening  and  brief  interventions 
be  provided  by  trained  professionals  in  all 
educational,  mental  health,  developmental 
disabilities,  child  welfare,  housing,  juvenile 


-15- 


justice  and  adult  corrections  services  that 
receive  public  funding;  and  that  patients 
who  screen  positive  for  risky  use  or  a 
potential  diagnosis  of  addiction  be 
connected  with  a  trained  health  professional 
for  intervention,  diagnosis,  treatment  and 
disease  management. 

Develop  tools  to  improve  service  quality. 

Federal  and  state  governments  in 
collaboration  with  professional  associations, 
accrediting  organizations  and  other  non- 
profit organizations  focusing  on  health  care 
quality  should  develop  and  disseminate 
evidence-based  tools,  practice  guidelines 
and  performance  measures  oriented  toward 
patient  outcomes  to  improve  the  quality  of 
addiction  care  (involving  all  substances)  and 
require  their  implementation  as  a  condition 
of  continued  licensure  and/or  accreditation. 

License  addiction  treatment  facilities  as 
health  care  providers.  Federal,  state  and 
local  governments  should  subject  all 
addiction  treatment  facilities  and  programs 
to  the  same  mandatory  licensing  processes 
as  other  health  care  facilities. 

Require  adherence  to  national 
accreditation  standards  that  reflect 
evidence-based  care.  As  a  condition  of 
licensure,  federal,  state  and  local 
governments  should  stipulate  that  all 
facilities  and  programs  providing  addiction 
treatment  adhere  to  established  national 
minimum  standards  for  accreditation. 

Require  that  all  insurers  provide 
coverage  for  comprehensive  addiction 
care.  Require  that  all  health  insurers- 
public  and  private— provide  coverage  for  all 
insured  individuals  for  patient  education, 
screening  and  intervention  for  risky 
substance  use  and  treatment  and 
management  of  addiction  (involving  all 
substances  associated  with  addiction) 
consistent  with  standards  of  medical 
practice,  eliminating  exemptions.  As  a 
condition  of  reimbursement,  public  payers 
and  private  insurance  companies  should  be 


mandated  to  require  that  all  addiction 
interventions  and  treatment  be  directly 
provided,  supervised  or  managed  by  trained 
medical  professionals.  Public  payers  and 
private  health  insurance  companies  should 
encourage  participating  providers  and 
facilities  to  adopt  evidence-based  practices, 
institute  quality-improvement  measures  and 
assess  patient  outcomes.  To  help  ensure 
comprehensive  coverage  and  appropriate 
medical  care,  the  Uniform  Accident  and 
Sickness  Policy  Provision  Law  (UPPL), 
which  bars  insurance  coverage  for  injuries 
sustained  by  a  person  who  was  under  the 
influence  of  alcohol  or  other  drugs  at  the 
time  of  the  injury,  should  be  eliminated. 

•  Expand  the  addiction  medicine 

workforce.  Accelerate  the  work  begun  by 
the  American  Board  of  Addiction  Medicine 
Foundation  to  develop  residency  training 
programs  in  addiction  medicine  and  secure 
residency  accreditation  from  the 
Accreditation  Council  for  Graduate  Medical 
Education  (ACGME).  Pursue  and  gain 
recognition  of  addiction  medicine  by  the 
American  Board  of  Medical  Specialties 
(ABMS).  Support  the  efforts  of  ACGME- 
accredited  addiction  psychiatry  residencies 
to  increase  the  number  of  enrolled  residents. 
Through  these  actions,  assure  that  addiction 
medicine  training  programs  are  available  to 
physicians,  that  training  opportunities  within 
addiction  psychiatry  are  expanded,  and  that 
such  specialty  care  is  formally  recognized 
and  available  in  every  hospital  throughout 
the  country  and  through  every  health  care 
system. 

•  Implement  a  national  public  health 
campaign.  Implement  a  nationwide  public 
health  campaign  through  federal  agencies 
charged  with  protecting  the  public  health  to 
educate  the  public  about  all  forms  of  risky 
substance  use  and  addiction. 

•  Invest  in  research  and  data  collection. 

Invest  in  research  designed  to  improve  and 
track  progress  in  addiction  prevention, 
treatment  and  disease  management  and  to 
find  a  cure  for  addiction. 


-16- 


Implement  the  National  Institutes  of 
Health's  (NIH)  recommendation  to  create 
a  single  institute  addressing  substance  use 
and  addiction.  Create  a  unified  national 
institute  focused  on  substance  use  and 
addiction,  recognizing  the  overarching 
disease  of  addiction  rather  than  continuing 
the  focus  on  different  manifestations  of  the 
disease-tobacco,  alcohol,  other  drug  use— 
and  including  the  risky  use  of  all  addictive 
substances.  Include  in  the  research  portfolio 
addiction  involving  behaviors  other  than 
substance  use,  and  focus  on  the  causes, 
correlates,  consequences,  interventions, 
policies  and  possible  cures  for  all 
manifestations  of  the  disease.  The  portfolio 
of  the  institute  also  should  include  health 
conditions  resulting  from  risky  use  and 
addiction  and  other  conditions  which 
increase  the  risk  of  developing  addiction. 


-18- 


Chapter  II 

What  Is  Addiction?  

Addiction*  is  a  complex  brain  disease  with 
significant  behavioral  characteristics. 1  In  many 
but  not  all  cases,  it  involves  the  use  of  nicotine, 
alcohol  and  other  drugs. '  Addiction  involving 
these  substances  typically  originates  with  use  in 
adolescence  when  the  brain  is  still  developing 
and  is  more  vulnerable  to  their  effects.2  If 
untreated,  it  can  become  a  chronic  and  relapsing 
condition,  requiring  ongoing  professional 
treatment  and  management.3 

Although  there  has  been  an  evolution  in 
scientific  understanding  of  the  disease,  public 
attitudes  and  health  care  practice  have  not  kept 
pace  with  the  science.  Terms  used  to  describe 
different  levels  of  substance  use  and  addiction's 
many  forms  lack  precision,  obscuring  important 
differences  in  the  use  of  addictive  substances 
and  the  nature  and  severity  of  the  illness  and 
complicating  our  ability  to  treat  it  effectively. 


In  this  report,  we  have  used  the  general  term 
addiction  to  apply  to  those  who  meet  criteria  for  past- 
month  nicotine  dependence  based  on  the  Nicotine 
Dependence  Syndrome  Scale  (NDSS)  and  those  who 
meet  diagnostic  criteria  for  past  year  alcohol  and/or 
other  drug  abuse  or  dependence  (excluding  nicotine) 
in  accordance  with  the  Diagnostic  and  Statistical 
Manual  of  Mental  Disorders  (DSM-IV).  (The  DSM 
refers  to  substance  abuse  and  substance  dependence 
as  substance  use  disorders.  The  criteria  for  nicotine 
dependence  in  the  NDSS  parallel  those  of  the  DSM- 
IV.)  This  definition  is  consistent  with  the  current 
move  to  combine  abuse  and  dependence  into  an 
overarching  diagnosis  of  addiction  in  the  upcoming 
DSM-V. 

1  Other  drugs  include  federally  controlled  illicit  drugs 
and  the  misuse  of  controlled  prescription  drugs.  The 
term  addiction  also  has  been  used  in  reference  to 
compulsive  behaviors  involving  eating,  gambling  and 
other  activities  that  affect  the  brain's  reward  system 
and  which  may  develop  independent  of  or  in 
combination  with  other  manifestations  of  addiction. 
This  report,  however,  focuses  only  on  addiction 
involving  nicotine,  alcohol  and  other  drugs. 


-19- 


Addiction  Is  a  Brain  Disease 

Advances  in  neuroscientific  research,  including 
animal  studies  and  brain  imaging,  demonstrate 
clearly  that  addiction  is  a  primary  and  often 
chronic  disease  of  the  brain.*  4  The  risk  factors 
for  developing  the  disease  include  a  genetic 
predisposition  and  a  range  of  biological, 
psychological  and  environmental  influences.5 
There  is  a  growing  body  of  evidence  showing 
the  brain  circuits  that  are  implicated  in  substance 
addiction  in  general  also  are  involved  in  other 
compulsive  or  addictive  behaviors  such  as  those 
related  to  gambling,  certain  forms  of  disordered 
eating  (e.g.,  bulimia,  obesity)  and  compulsive 
sexual  activity.   For  these  reasons,  researchers 
are  beginning  to  explore  whether  substance 
addiction  might  be  part  of  a  syndrome 
characterized  by: 

•  Shared  neurobiological  and  psychosocial 
antecedents  (risk  factors); 

•  Production  of  desirable  effects  upon 
involvement  with  the  rewarding  object  or 
activity; 

•  Shared  manifestations  and  outcomes  (e.g., 
biological  ones  such  as  tolerance  or 
withdrawal  or  behavioral  or  psychological 
ones  such  as  deceit,  shame,  guilt  or 
depression);  and 

•  A  shared  course  of  the  disease  (e.g., 
improvement,  relapse,  remission  and  the 
potential  for  progression  to  disability  or 
death).7 


A  primary  disease  indicates  that  it  is  not  simply  a 
symptom  or  effect  of  another  disease  or  condition. 


The  focus  of  this  report  is  on  addiction  involving 
nicotine,  alcohol  and  other  drugs.  Use  of  these 
substances  can  result  from  an  existing  brain 
dysfunction;  use  also  can  alter  the  structure  and 
function  of  the  brain,  dramatically  affecting 
judgment  and  behavior.8  The  amount  and 
duration  of  substance  use  that  results  in  brain 
changes  and  addiction  depends  on  the  individual 
and  the  particular  substances  used. f  9 

As  yet,  there  is  no  conclusive  biological  marker 
of  addiction;  therefore  the  diagnosis  of  addiction 
is  based  on  its  symptoms  including  the 
compulsive  use  of  addictive  substances, 
significantly  impaired  function  and  persistent 
use  despite  negative  consequences.1 10  These 
symptoms  that  characterize  addiction  are 
cognitive  and  behavioral  manifestations  of  the 
underlying  disease  and  its  effects  on  the  brain. 1 1 
The  foundations  of  the  disease  may  exist  in 
certain  individuals  even  before  they  ever  use  an 
addictive  substance  and,  in  some  cases,  once  the 
disease  develops  it  persists  even  when  an 
individual  is  not  actively  engaged  in  substance 


1  The  addictive  potential  of  a  substance  is 
determined  not  only  by  its  intrinsic  ability  to 
stimulate  the  reward  circuits  of  the  brain,  but  also  by 
the  speed  with  which  it  crosses  the  blood-brain 
barrier  (i.e.,  how  soon  after  initial 
ingestion/injection/inhalation  it  reaches  receptors  in 
reward  circuits  of  the  brain). 
*  Other  physical  signs  such  as  intoxication, 
withdrawal,  needle-related  findings,  co-infections, 
and  laboratory  findings— such  as  abnormalities  in 
liver  function  tests  or  positive  breath  or  urine  tests- 
can  aid  in  the  diagnosis. 


...addiction  is  not  about  drugs,  it's  about 
brains.  It  is  not  the  substances  a  person  uses 
that  make  them  an  addict;  it  is  not  even  the 
quantity  or  frequency  of  use.  Addiction  is  about 
what  happens  in  a  person 's  brain  when  they  are 
exposed  to  rewarding  substances  or  rewarding 
behaviors,  and  it  is  more  about  reward  circuitry 
in  the  brain  and  related  brain  structures  than  it 
is  about  the  external  chemicals  or  behavior  that 
"turn  on  "  that  reward  circuitry. 14 


Unfortunately,  keeping  the  emphasis  on  just  the 
behavioral  manifestations  presumes  that  the 
problem  is  present  when  the  behavior  is  present 
and  the  problem  is  resolved  if  the  behavior  is  not 
present  for  whatever  duration  of  time,  even 
though  the  underlying  disease  process  may  be 
present  and  even  progressing,  or  contributing  to 
other  manifestations,  signs  and  symptoms  that 
may  be  overlooked. 13 


-20- 


The  areas  of  the  brain  affected  by  this  complex 
disease  are  among  those  that  are  responsible  for 
survival-including  the  areas  associated  with 
motivation,  decision  making,  risk  and  reward 
assessment,  pleasure  seeking,  impulse  control/ 
inhibition,  emotion,  learning,  memory  and  stress 
control.15 

In  order  to  reinforce  activities  necessary  for 
survival,  the  brain  produces  feelings  of  pleasure 
in  response  to  the  satisfaction  of  fundamental 
drives  such  as  hunger,  thirst  and  sex.16 
Behaviors  that  lead  to  these  rewards  tend  to  be 
reinforced  and  thus  perpetuated  over  time.17  On 
a  neurological  level,  this  reinforcement  is  a 
process  carried  out  by  chemical  messengers  that 
flood  the  reward  circuits  of  the  brain.18 
Virtually  all  addictive  substances  affect  the 
pleasure  and  reward  circuitry  deep  in  the  brain* 
which  is  activated  by  the  neurotransmitter 
dopamine.'  19 


*  The  mesolimbic  reward  system. 
'  The  neurotransmitter  serotonin  also  is  involved  in 
some  forms  of  substance  addiction;  it  plays  a  role  in 
motivated  or  directed  actions  such  as  attaining 
addictive  substances  and  also  influences  dopamine 
levels  in  the  brain.  Hallucinogenic  drugs  like  LSD 
and  Ecstasy  target  serotonin  systems  in  the  brain. 


Addictive  substances  drive  behavior  by  causing 
the  release  of  more  dopamine  within  brain 
reward  circuits  than  almost  all  natural  rewards 
including  those  tied  to  food  and  sex.20  With 
repeated  use  of  addictive  substances,  the  brain 
begins  to  expect  this  stimulation  and  an  addicted 
individual  may  experience  intense  desire  or 
cravings  whenever  the  addictive  substances  are 
not  readily  available  and  especially  when  the 
individual  is  exposed  to  cues  associated  with 
substance  use.21  Recent  research  points  to 
evidence  that  use  of  one  addictive  substance  can 
increase  the  risk  of  use  of  and  addiction 
involving  another  substance;  for  example, 
nicotine  use  can  prime  the  brain,  making  it  more 
susceptible  to  developing  addiction  involving 
cocaine.* 22  Signals  in  the  environment  such  as 
seeing  a  drug-using  friend  or  passing  a  bar,  or 
emotional  signals  such  as  feeling  stressed  or  sad 
also  become  associated  with  the  addictive 
substance  and  spur  the  drive  to  obtain  it.23 

As  use  continues,  the  pleasure  associated  with 
the  dopamine  release  that  results  from  the 
ingestion  of  an  addictive  substance— or  from  its 
anticipation-can  become  consuming  to  the  point 
where  fundamental  natural  drives  and  associated 
behaviors  lose  their  value  in  comparison.25 

At  the  same  time,  the  brains  of  substance-using 
individuals  may  adapt  to  the  unnaturally  high 
levels  of  dopamine  that  result  from  continued 
substance  use  and  may  respond  by  reducing  the 
normal  release  of  dopamine  as  well  as  the 
number  of  dopamine  receptors  in  the  brain.26 
When  this  happens,  the  addictive  substance  may 
become  necessary  just  for  the  person  to  feel 
normal.27  Compared  to  non-substance  users,  the 
brains  of  chronic  substance  users  appear  to  have 
lower  baseline  levels  of  dopamine,  making  it 
difficult  for  them  to  achieve  feelings  of  pleasure 
from  substance  use  and  other  behaviors  that 
once  were  pleasurable.28 

Changes  in  the  function  and  structure  of  the 
brain  result  in  specific,  compulsive  behaviors 
aimed  at  obtaining  and  using  addictive 
substances.29  The  cognitive  control  of  an 


1  This  study  provides  a  biological  mechanism  for  the 
"gateway  effect." 


Definition  of  Addiction 
American  Society  of  Addiction  Medicine 

Addiction  is  a  primary,  chronic  disease  of  brain 
reward,  motivation,  memory  and  related  circuitry. 
Dysfunction  in  these  circuits  leads  to 
characteristic  biological,  psychological,  social  and 
spiritual  manifestations.  This  is  reflected  in  an 
individual  pathologically  pursuing  reward  and/or 
relief  by  substance  use  and  other  behaviors. 

Addiction  is  characterized  by  inability  to 
consistently  abstain,  impairment  in  behavioral 
control,  craving,  diminished  recognition  of 
significant  problems  with  one's  behaviors  and 
interpersonal  relationships  and  a  dysfunctional 
emotional  response.  Like  other  chronic  diseases, 
addiction  often  involves  cycles  of  relapse  and 
remission.  Without  treatment  or  engagement  in 
recovery  activities,  addiction  is  progressive  and 
can  result  in  disability  or  premature  death.24 


-21- 


addicted  individual  is  so  weakened  that  even 
when  he  or  she  wants  to  cut  down  or  stop  using 
an  addictive  substance,  it  becomes  extremely 
difficult  to  do  so.30 


People  may  choose  to  take  drugs,  but  no  one 
chooses  to  be  an  addict. 

-Participant 
CASA  Columbia  Focus  Group 
May  2008,  Philadelphia,  PA 


The  Risk  Factors  for  Addiction 

Genetic  factors  play  a  major  role  in  the 
development  of  addiction  as  do  individual 
biological  and  psychological  characteristics  and 
environmental  conditions.31  These  factors  affect 
both  the  initial  use  of  an  addictive  substance  and 
the  progression  from  initiation  of  substance  use 
to  regular  use  to  addictive  use.32 

Whereas  biological,  psychological  and 
environmental  factors— such  as  impairments  in 
the  brain's  reward  circuitry,  compensation  for 
trauma  and  mental  health  problems,  easy  access 
to  addictive  substances,  substance  use  in  the 
family  or  media  and  peer  influences-play  a 
large  role  in  whether  an  individual  starts  to 
smoke,  drink  or  use  other  drugs,33  genetic 
factors  are  more  influential  in  determining  who 
progresses  to  risky  use  or  addiction.34  A  factor 
that  is  particularly  predictive  of  risk,  however,  is 
the  age  of  first  use;  almost  all  cases  of  addiction 
begin  with  substance  use  before  the  age  of  2 1 , 
when  the  brain  is  still  developing.35 


development  of  addiction.    Although  certain 
specific  genetic  factors  predispose  an  individual 
to  addiction  involving  a  particular  substance,37 
genetic  factors  also  appear  to  contribute 
generally  to  the  risk  of  use  and  addiction.38 
Advances  in  genetic  research  have  enabled 
scientists  to  identify  individual  genes,  including 
genetic  variations  in  components  of  the 
dopamine  transmission  system,39  implicated 
both  in  the  likelihood  of  substance  use  and  of 
addiction  involving  a  variety  of  substances.40 

Genetic  variations  may  affect  a  person's  ability 
to  metabolize  an  addictive  substance41  or  to 
tolerate  it.42  Studies  have  found  that  genetics 
account  for  between  half  and  three  quarters  of 
the  risk  for  addiction. '  43  Genetic  factors  appear 
to  be  stronger  drivers  than  environmental  factors 
of  initiation  of  substance  use  at  an  early  age.44 

Nicotine.  Adolescents  who  do  not  have  a 
certain  variant  of  the  gene  that  is  responsible  for 
the  enzyme  that  metabolizes  nicotine*  progress 
from  smoking  to  addiction  involving  nicotine 
faster  than  adolescents  with  that  type  of  gene.45 
Other  genetic  variations  in  genes  that  determine 
how  nicotine  receptors  in  the  brain  function5 
also  are  linked  to  increased  risk  of  addiction 
involving  nicotine  and  difficulty  quitting 
smoking.46 

Alcohol.  Individuals  whose  genetic  makeup 
influences  them  to  have  a  higher  tolerance  for 
alcohol  are  at  increased  risk  of  developing 


Genetic  Risks 


Twin  and  adoption  studies  confirm  a  genetic 
role  in  the  likelihood  of  substance  use  and  the 


These  studies  help  distinguish  the  roles  of  genetics 
and  environment  in  the  development  of  addiction. 
Studies  of  adopted  children  allow  researchers  to 
compare  the  adopted  child  both  to  her  biological 
parents  with  whom  she  shares  genetic  features  but  no 
environmental  experiences  and  to  her  adopted  parents 
with  whom  she  shares  environmental  experiences  but 
no  genetic  features.  Studies  of  identical  and  fraternal 
twins  allow  researchers  to  isolate  genetic  similarities 


from  environmental  similarities.  Identical  twins  are 
genetically  identical  and  fraternal  twins  share  an 
average  of  50  percent  of  their  genes,  but  both  types  of 
twins  typically  experience  a  shared  environment  if 
reared  together. 

f  The  majority  of  the  genetics  literature  focuses  on 

addiction  involving  alcohol;  the  estimated  extent  of 

genetic  influence  on  addiction  involving  other  drugs 

varies  by  the  type  of  drug. 

*  CYP2A6. 

§  e.g.,  CHRNA5. 


-22- 


addiction.      Adopted  children  with  biological 
parents  who  have  addiction  involving  alcohol 
are  at  least  twice  as  likely  as  are  adopted 
children  without  such  parents  to  develop 
addiction  involving  alcohol.48  Individuals 
whose  genetic  makeup  produces  involuntary 
skin  flushing  and  other  unpleasant  reactions  to 
alcohol  are  at  reduced  risk  of  developing 
addiction  involving  alcohol.49 


Other  Drugs.  Genetic  influences  have  been 
implicated  in  marijuana  use51  and  particular 
genes  have  been  associated  with  marijuana 
cravings  and  withdrawal  symptoms.52  Twin 
studies  have  found  genetic  risks  for 
hallucinogen,  opioid,  sedative  and  stimulant  use 
and  addiction.53 

Biological  Risks 

In  addition  to  genetic  variations,  certain 
individuals  have  neurological,  structural  or 
functional  differences  that  make  them  more 
susceptible  to  addictive  substances.54  This  is  in 
part  due  to  individual  differences  in  how  the 
brain  produces  and  reacts  to  dopamine.55  Some 
research  indicates  that  individuals  with  a 
naturally  low  level  of  dopamine  response  to 
addictive  substances  are  at  increased  risk  of 
engaging  in  substance  use  in  order  to  achieve  a 
greater  experience  of  reward.  Other  research 
suggests  that  individuals  with  a  biological 


There  is  some  indication  that  these  individuals  have 
less  cognitive  impairment  following  the  ingestion  of 
alcohol  and,  therefore,  may  not  perceive  the  negative 
experiential  aspects  of  alcohol  use  in  the  same 
manner  as  individuals  whose  brains  are  more  strongly 
affected  by  alcohol  ingestion. 


tendency  toward  heightened  dopamine  response 
also  are  at  increased  risk  because  of  their 
enhanced  or  above  average  experience  of  reward 
or  pleasure  from  engaging  in  substance  use.56 
Other  biological  risks  may  involve  damage  or 
deficits  in  the  regions  of  the  brain'  responsible 
for  decision  making  and  impulse  control.57 

Psychological  Risks 

Clinical  mental  health  disorders  such  as 
depression  and  anxiety  and  psychotic  disorders 
such  as  schizophrenia,  as  well  as  behavioral 
disorders  such  as  conduct  disorder  and  attention- 
deficit/hyperactivity  disorder58— and  sub-clinical 
symptoms  of  these  conditions59~are  strongly 
linked  to  substance  use  and  addiction  and  to  the 
risk  of  transitioning  from  substance  use  to 
addiction.60  Individuals  whose  brain 
development  has  been  altered  by  stress  are  more 
sensitive  to  the  effects  of  addictive  substances 
and  more  vulnerable  to  the  development  of 
addiction.61  Likewise,  individuals  with  post- 
traumatic stress  disorder  (PTSD),  common 
among  veterans  and  individuals  in  active 
military  duty,  are  at  increased  risk  of  developing 
addiction.62  People  who  have  risk-taking  or 
impulsive  personality  traits63  or  who  have  low 
self-esteem64  also  are  likelier  to  engage  in 
substance  use65  as  are  victims  of  trauma  or 
abuse.66  Expectations  play  a  role  in  substance 
use  as  well,  since  people  who  expect  that  using 
addictive  substances  will  be  a  positive  and 
rewarding  experience—in  terms  of  physical 
effects,  mood  or  behavior— are  likelier  to  smoke, 
drink  alcohol  or  use  other  drugs  than  are  those 
with  more  balanced  or  negative  expectations.67 

Environmental  Risks 

Many  factors  within  an  individual's  family, 
social  circle  and  community,  as  well  as  the 
larger  cultural  climate,  increase  the  likelihood 
that  an  individual  will  use  addictive  substances 
and  develop  addiction. 


'  e.g.,  in  the  orbitofrontal  cortex  and  anterior 
cingulate  cortex. 


It's  theoretically  possible  to  take  kids  before 
they  first  drink,  find  out  whether  they  have  any 
gene  variations,  and  say  to  them,  'If  you  choose 
to  be  a  drinker,  then  be  careful  because  it's  very 
likely  that  you  '11  need  to  drink  more  to  have  the 
same  effect. ' 50 

-Marc  A.  Schuckit,  MD 
Distinguished  Professor  of  Psychiatry 
Department  of  Psychiatry 
University  of  California,  San  Diego 


-23- 


People  who  grow  up  in  homes  in  which  parents 
routinely  expose  their  children  to  smoking, 
excessive  drinking  or  other  drug  use  are  at 
increased  risk  of  substance  use,  as  are  those 
whose  parents  do  not  convey  strong  anti- 
substance  use  messages  and  expectations.68  The 
nature  of  the  parent-child  relationship  is  key; 
people  who  come  from  families  with  high  levels 
of  parent-child  conflict,  poor  communication, 
weak  family  bonds  and  other  indicators  of  an 
unhealthy  parent-child  relationship  are  at 
increased  risk  of  substance  use  and  addiction.69 
Individuals  whose  peers  engage  in  substance  use 
or  convey  approval  of  such  use  are  at  increased 
risk  as  well.70 

The  simple  fact  of  availability  of  addictive 
substances  makes  it  likelier  that  an  individual 
will  use  them.72  Homes  where  liquor  and 
medicine  cabinets  are  open  to  teens  increase  the 
chances  that  teens  will  use  these  substances.73 
People  who  live  in  communities  where  addictive 
substances  are  readily  available,  where  using 
such  substances  is  considered  normal  or 
expected  or  where  tobacco  and  alcohol  retail 
outlets  are  prevalent  are  at  increased  risk.74 
Widespread  access  to  controlled  prescription 
drugs  contributes  to  the  misuse  of  these 
substances75  and  increased  access  to  marijuana 
marketed  as  medicine  is  linked  to  increased 
use.76  Community  tolerance  of  high  levels  of 
substance  use  or  of  experimenting  with  and 
using  addictive  substances  as  a  normal  rite  of 
passage  for  adolescents  also  increases  the  risk  of 
use,  as  does  lax  enforcement  of  governmental 
policies  and  regulations  restricting  use.77 

Exposure  to  advertising  and  marketing  messages 
that  promote  or  glamorize  smoking  and  drinking 
increases  the  chances  that  these  substances  will 
be  used  and  misused.78  Direct-to-consumer 
marketing  of  controlled  prescription  drugs  may 
encourage  substance  use  by  conveying  the 
message  that  there  is  a  pill  for  every  ill.79 

Environmental  influences  can  exacerbate 
existing  genetic,  biological  and  psychological 
risks  for  substance  use,  further  increasing  the 
chances  that  an  individual  will  engage  in  risky 
substance  use,  sometimes  to  the  point  of 
addiction.80 


Early  Initiation  of  Use 

Adolescence  is  the  critical  period  of 
vulnerability  for  the  onset  of  substance  use  and 
the  development  of  addiction.81  In  96.5  percent 
of  cases,  addiction  originates  with  substance  use 
before  the  age  of  21. 82  Because  the  parts  of  the 
brain  responsible  for  judgment,  decision- 
making, emotion  and  impulse  control  are  not 
fully  developed  until  early  adulthood, 
adolescents  are  more  likely  than  adults  to  take 
risks,  including  experimenting  with  addictive 
substances.83  At  the  same  time,  because  these 
regions  of  the  brain  are  still  developing,  they  are 
more  vulnerable  to  the  negative  impact  of 
addictive  substances,  further  impairing 
judgment,  interfering  with  brain  development 
and  increasing  the  risk  of  addiction.* 84  The 
combination  of  early  initiation  of  use  and 
genetic,  biological,  psychological  or 
environmental  risk  factors  dramatically  hike  the 
chances  that  addiction  will  develop.85 
Adolescents  with  a  genetic  predisposition  to 
addiction  and/or  co-occurring  mental  health 
problems  are  at  the  greatest  risk  of  progressing 
from  substance  use  to  addiction.86 


...  [addiction]  is  not  simply  a  disease  of  the 
brain,  but  it  is  a  developmental  disorder,  and  it 

71 

begins  early  in  life— during  adolescence. 

-Nora  D.  Volkow,  MD 
Director 

National  Institute  on  Drug  Abuse  (NIDA) 


Risky  Use  and  Addiction 
Frequently  Co-occur  with  Other 
Health  Conditions 

Individuals  with  addiction  are  likely  to  have  co- 
occurring  health  conditions.87  Smoking  causes 
bladder,  esophageal,  laryngeal,  lung  and  oral 
cancer.88  From  2000-2004,  the  top  three  causes 
of  smoking-attributable  death  were  lung  cancer, 


As  is  true  of  much  of  health  research,  the  research 
on  the  neurological  effects  of  addictive  substances  on 
the  adolescent  brain  primarily  has  been  conducted  on 
animals. 


-24- 


ischemic  heart  disease  and  chronic  obstructive 
pulmonary  disease.89  Alcohol  consumption 
contributes  to  diseases  that  are  among  the  top 
causes  of  death,  including  heart  disease,  cancer 
and  stroke.90  Addiction  involving  alcohol  is 
linked  to  cirrhosis,  alcoholic  hepatitis,  chronic 
pancreatitis,  cardiomyopathy,  heart  arrhythmias, 
stroke  and  neoplasms  of  the  liver,  pancreas  and 
esophagus.91  Heavy  alcohol  use  and  addiction 
involving  alcohol  are  associated  with  the 
incidence  and  re-infection  of  tuberculosis.92 
Injection  drug  use  is  a  risk  factor  for  infectious 
diseases,  including  HIV,  hepatitis  C  and 
hepatitis  B.93  The  incidence  of  various  forms  of 
cancer,94  heart  disease95  and  sexually-transmitted 
diseases96  are  higher  among  those  with  addiction 
than  among  those  without  addiction. 

Risky  use  and  addiction  also  have  high  rates  of 
co-occurrence  with  many  mental  health 
problems  including  depression,  anxiety,  post- 
traumatic stress  disorder,  bipolar  disorder, 
schizophrenia  and  other  neuropsychiatric 
disorders  such  as  attention  deficit/hyperactivity 
disorder,  conduct  disorder  and  eating 
disorders.98  The  association  between  addiction 
and  co-occurring  health  conditions  can  result 
from  several  factors.  Substance  use  may 
precipitate  the  onset  of  other  conditions  such  as 
depression  or  anxiety  disorders.99  Other  times, 
the  health  conditions  may  precede  the  onset  of 
addiction,  as  often  occurs  with  mood  disorders 
and  attention  deficit/hyperactivity  disorder,100  as 
individuals  attempt  to  self-medicate  the  pain  or 
distress  associated  with  their  illness.101  The  two 
types  of  conditions  also  may  co-occur  as  a 
function  of  an  underlying  psychological  or 
biological  propensity,  or  substance  use  can 
exacerbate  or  complicate  symptoms  of  existing 
health  conditions.102 


the  risk  of  relapse.  In  these  cases,  addiction  is  a 
chronic  disease-like  heart  disease,  hypertension, 
diabetes  and  asthma— defined  as  having  a  clear 
biological  basis,  a  behavioral  component, 
environmental  influences,  unique  and 
identifiable  signs  and  symptoms,  a  predictable 
course  and  outcome  and  the  need  for  continued 
management  following  treatment.104 

Like  any  other  chronic  condition,  addiction 
rarely  abates  after  a  single  course  of  medication 
or  other  treatment  or  after  a  single  attempt  to 
alter  one's  lifestyle  or  behavior.  As  is  true  of 
other  chronic  conditions,  individuals  with 
addiction  can  have  symptom-free  periods  and 
periods  of  relapse.105  Many  patients  relapse 
multiple  times  and  still  others  never  achieve 
effective  disease  management.106  In  fact, 
addiction  frequently  is  characterized  as  a  disease 
where  relapse  is  virtually  inevitable.  Yet,  this 
conception  of  addiction  might  be  due  to  the 
focus  of  research  studies  on  those  with  the  most 
severe  manifestations  of  addiction,  who 
experience  multiple  episodes  of  symptom 
relapse  and  co-existing  health  and  social 
problems  over  the  course  of  many  years  or  even 
a  lifetime.107  Furthermore,  very  few  people  with 
addiction  actually  receive  adequate,  effective, 
evidence-based  treatment.108  The  seemingly 
high  rates  of  relapse*  may  be  due,  at  least  in 
part,  to  inadequate  or  ineffective  interventions 
and  treatments.109 


It's  not  surprising  to  us  now  that  when  you  stop 
the  treatment,  people  relapse.  It  doesn  't  mean 
that  the  treatment  doesn 't  work,  it  just  means 
that  you  need  to  continue  treatment.91 

-Daniel  Alford,  MD,  MPH 
Associate  Professor  of  Medicine 
Boston  University  School  of  Medicine 


Addiction  Can  Be  a  Chronic 
Disease 

Once  an  individual  develops  addiction,  changes 
in  the  brain's  reward  circuitry  may  remain  even 
after  cessation  of  substance  use.103  These 

changes  leave  addicted  individuals  vulnerable  to  

physiological  and  environmental  cues  that  they  *  Relapse  rates  for  those  with  addiction  are 

have  associated  with  substance  use,  increasing  comparable  to  relapse  rates  for  those  with  other 

chronic  diseases. 


-25- 


Models  for  Understanding 
Addiction 

The  model  for  how  we  understand  addiction  is 
critical  because  it  influences  how  individuals 
with  addiction  are  treated  in  society  and  guides 
the  nature  of  the  services  provided  to  address  the 
disease.110  The  current  model  of  addiction 
recognizes  that  it  is  a  complex  brain  disease111 
and  that  multiple  determinants  and  systems 
influence  substance  use  and  its  progression  to 
addiction.112  Although  this  model  is  based  on  a 
large  and  growing  body  of  scientific  evidence, 
treatment  practice  and  public  attitudes  still 
reflect  earlier  models  of  understanding  the 
condition. 

Since  the  1700s,  with  few  exceptions,113  two 
different  models  have  dominated  society's  views 
on  addiction,  driven  in  large  part  by 
sociopolitical  influences  and  also  by  developing 
knowledge  about  the  science  of  addiction. 1 14 

The  moral  model  of  addiction  framed  addiction 
primarily  as  a  failure  of  personal  responsibility 
or  morality.  It  asserted  that  addiction  could  be 
addressed  simply  by  requiring  personal 
responsibility  and  accountability  on  the  part  of 
the  person  who  is  addicted.  This  approach  has 
contributed  to: 

•  The  stigma  associated  with  addiction, 
attaching  blame  to  the  individual,  creating 
shame  and  embarrassment,  increasing  the 
likelihood  of  discrimination  and  decreasing 
the  chances  that  the  addicted  individual  will 
seek  or  receive  effective  treatment.115 

•  Restrictions  in  benefits  for  addicted 
individuals.  In  1995,  a  Congressional  vote 
discontinued  Supplemental  Security  Income 
(SSI)  disability  benefits  to  individuals 
whose  primary  diagnosis  was  addiction 
involving  alcohol  or  other  drugs.116  And, 
the  majority  of  states  in  the  U.S.  currently 
are  proposing  or  adopting  legislation  that 
condition  the  receipt  of  public  services 
including  welfare,  unemployment 
assistance,  job  training,  food  stamps  and 
public  housing  on  passing  a  drug  test.117 


The  disease  model  of  addiction,  in  contrast  to  the 
moral  model,  acknowledged  biology  and 
genetics  as  significant  contributors  to  addiction, 
drawing  on  advances  in  genetics  and  brain 
research. 1    This  approach  has  contributed  to  the 
concern  that  viewing  addiction  as  a  disease 
might: 

•  Release  the  individual  from  personal 
responsibility  and  the  need  for  self- 
control,119  and 

•  Engender  feelings  of  hopelessness  with 
regard  to  effective  treatment  and  the 
possibility  of  recovery.120 

These  concerns,  however,  rarely  are  raised  in 
relation  to  other  health  problems  and  appear,  at 
least  in  part,  to  be  reflective  of  the  moral  model 
of  addiction. 

Evolving  Approaches  to  Addressing 
Addiction 

America's  approach  to  addressing  substance  use 
and  addiction  has  been  filled  with  contradiction. 
For  example,  at  the  turn  of  the  20th  century, 
cigarette  smoking  was  frowned  upon.121  Thanks 
to  effective  marketing  by  the  tobacco  industry, 
that  view  was  replaced  by  one  of  tobacco  use  as 
glamorous  and  even  healthful,122  only  to  be 
supplanted  in  the  mid- 1 960s  by  a  growing 
understanding  that  cigarette  smoking  is  a 
significant  contributor  to  poor  health  and 
disease.123 

Physicians  prescribed  marijuana  and  cocaine  for 
a  variety  of  ailments  in  the  late  part  of  the  1 9th 
century  only  to  scale  back  in  the  first  decades  of 
the  20th  century  in  response  to  increasing 
recognition  of  the  adverse  effects  of  these  drugs 
and  increasing  regulatory  restrictions  on  their 
use;  today,  there  is  a  return  to  attempting  to 
frame  marijuana  as  medicine.124  Similarly, 
opium  was  used  in  the  early  part  of  the  last 
century  to  treat  diarrhea,  dysentery  and 
coughs.125  In  response  to  the  proliferation  of 
marijuana,  hallucinogen,  cocaine  and  heroin  use 
in  the  late  1960s  and  early  1970s-and  their 
association  with  political  protest,  crime  and 


-26- 


addiction— and  to  the  emerging  "crack  epidemic" 
in  the  late  1980s,  substance  use  and  addiction 
increasingly  were  criminalized.126  This  trend 
toward  criminalization  was  reflected  in  federal 
and  state  laws  such  as  New  York's  Rockefeller 
Drug  Laws  which  created  mandatory  minimum 
sentences  of  15  years  to  life  for  possession  of 
four  ounces  of  narcotics  (about  the  same  as  a 
sentence  for  second-degree  murder).127  Later, 
prescription  opioid  medications  were  heavily 
marketed  for  pain  which  led  to  increased 
negative  consequences  associated  with  their  use 
and  renewed  calls  for  increased  legal 
restrictions.128  (See  Text  Box  on  page  28.) 

The  latter  half  of  the  20th  century  has  seen  more 
systematic  and  consistent  progress  in  how 
addiction  is  perceived  in  the  medical  field.  In 
1956,  the  American  Medical  Association 
(AMA)  declared  that  alcoholism  is  an  illness  and 
that  it  can  and  should  be  treated  within  the 
medical  profession;130  in  1967,  the  AMA 
elaborated  on  this  position  in  a  manual  for 
physicians  declaring  that  alcoholism  is 
characterized  by  a  distinct  pattern  of  symptoms, 
chronicity,  progression,  and  by  a  tendency 
toward  relapse  and  that  it  should  be  treated  by 
physicians.131  The  U.S.  Comprehensive  Alcohol 
Abuse  and  Alcoholism  Prevention,  Treatment, 
and  Rehabilitation  Act  of  1970  recognized 
alcoholism  as  "an  illness  requiring  treatment  and 
rehabilitation."132 


Alcoholism  must  be  regarded  as  within  the 
purview  of  medical  practice.  The  Council  on 
Mental  Health,  its  Committee  on  Alcoholism,  and 
the  profession  in  general  recognizes  this  syndrome 
of  alcoholism  as  illness  which  justifiably  should 
have  the  attention  of 'physicians. ,133 

—American  Medical  Association 
Reports  of  Officers 
Report  of  the  Board  of  Trustees,  1956 


In  1979,  the  AMA  Council  on  Scientific  Affairs 
published  Guidelines  for  Physician  Involvement 
in  the  Care  of  Substance-Abusing  Patients 
which  put  the  weight  of  policy  behind  the 
declaration  that  physicians  are  responsible  for 
addressing  alcohol  and  other  drug  use  in  their 


patients  by  engaging  in  diagnosis  and  referral  (at 
a  minimum)  and  preferably  interventions  that 
would  ready  the  patient  for  treatment  or  actually 
providing  treatment  and  follow-up  care;  the 
guidelines  also  specify  the  actions  and 
knowledge  required  for  each  level  of  physician 
involvement.134  In  1989,  a  third  of  a  century 
after  declaring  that  alcoholism  is  a  disease,  the 
AMA  adopted  a  policy  declaring  addiction 
involving  other  drugs-including  nicotine-to  be 
a  disease.135 

Addiction  involving  alcohol  and  other  drugs  first 
was  viewed  by  the  field  of  psychiatry  as  a 
symptom  of  an  underlying  personality  disorder 
in  1952; 136  in  1980,  addiction  involving  nicotine, 
alcohol  and  other  drugs  was  described  by  the 
American  Psychiatric  Association  (APA) f  as  an 
independent  disorder-a  substance  use  disorder 
for  which  the  clinician  was  instructed  to  specify 
the  substance  involved  in  the  addiction.137 

From  the  mid- 1 990s  through  the  present  day 
there  has  been  a  growing  backlash  against  a 
punitive  approach  to  individuals  with 
addiction,138  concomitant  with  the  growth  in 
scientific  understanding  of  the  brain  processes 
underlying  addiction  and  the  development  of 
evidence-based  pharmaceutical  and  psychosocial 
therapies  to  treat  it.139  Yet  it  was  not  until  the 
late  1 990s  that  addiction  began  to  gain  broader 
recognition  as  a  brain  disease.140 


The  history  of  addiction  as  a  brain  disease  looks 
a  lot  like  the  history  of  atoms  or  germs,  insofar 
as  these  were  all  older  and  controversial  ideas 
for  which  scientific  confirmation  later  became 
available.™ 

-David  T.  Courtwright,  PhD 
Professor,  Department  of  History 
University  of  North  Florida 


By  the  American  Psychiatric  Association's 
Diagnostic  and  Statistical  Manual  of  Mental  Disorder 
(DSM),  first  edition.  (See  page  31  for  a  description 
oftheDSM.) 
1  In  the  DSM-III. 


-27- 


Select  Examples  of  Shifting  Perceptions 
of  Harms  and  Benefits  of  Addictive  Substances  in  the  U.S. 

Tobacco.  Cigarette  smoking  generally  was  frowned  upon  at  the  turn  of  the  20th  century.141  However,  highly 
effective  marketing  campaigns  conducted  during  the  early  and  mid-20th  century  by  the  major  tobacco  companies 
tremendously  enhanced  the  appeal  of  smoking  for  men  and  women  alike.  The  image  of  the  cigarette  smoker 
projected  by  such  campaigns— and  by  the  entertainment  media— was  that  of  glamour,  sophistication  and  even  fitness. 
Some  medical  professionals  even  signed  on  to  the  health  message;  tobacco  advertisements  featured  physicians  and 
some  appeared  in  medical  journals. 142  In  1950,  a  landmark  study  linking  smoking  to  lung  cancer  was  published  in 
the  prestigious  Journal  of  the  American  Medical  Association. 143  Over  the  next  decade,  more  than  7,000  articles  were 
published  linking  smoking  with  lung  cancer  and  other  life -threatening  diseases.1    In  1964,  the  first  U.S.  Surgeon 
General's  Report  on  Smoking  and  Health  was  published,  concluding  that  smoking  was  hazardous  to  health  and  that 
immediate  action  was  warranted.145  It  spurred  a  major,  highly  successful  public  health  effort  to  reduce  smoking  and 
other  tobacco  use.  The  truth  about  the  dangers  of  smoking  and  the  health  consequences  of  second-hand  smoke, 
finally  reached  the  public  through  unmistakable  health  evidence  and  powerful  anti-tobacco  health  and  legal 
campaigns.  Perceptions  of  smoking  (and  smokers)  largely  turned  negative,  public  policy  shifted  toward  widespread 
bans  and  restrictions  on  smoking,  and  smoking  rates  have  declined  significantly. 

Alcohol.  The  duality  of  alcohol— as  a  staple  for  celebrations,  religious  rituals  or  relaxing  with  family  and  friends,  and 
on  the  other  hand  as  an  underlying  driver  of  crime,  poverty,  family  dysfunction  and  illness-has  a  very  long  history. 
Alcohol  was  considered  in  early  America  to  be  helpful  for  curing  ailments,  natural  and  healthy  when  used  in 
moderation,  as  an  important  source  of  nutrients  and  as  a  healthier  alternative  to  water  which  often  was 
contaminated.146  The  19th  and  early  20th  centuries  saw  a  change  in  attitudes  wherein  excessive  alcohol  use  was  seen 
as  an  impediment  to  worker  productivity  and  as  a  contributing  factor  to  problems  such  as  domestic  violence,  poverty 
and  crime.147  The  initial  push  for  moderation  in  alcohol  use  (temperance)  soon  became  a  push  for  prohibition.148 
Once  the  futility  of  prohibition  became  apparent  and  the  law  ultimately  repealed,  alcohol  has  been  both  extolled 
through  ubiquitous  marketing  and  condemned  for  its  tremendous  societal  and  health-related  costs.  Conflicting  views 
on  the  dangers  versus  benefits  of  alcohol  use  persist  with  a  growing  list  of  scientific  findings  that  the  health  and 
social  risks  of  excessive  alcohol  use  and  dangers  of  underage  drinking  outweigh  any  ostensible  health  benefits  of 
non-excessive  drinking. 

Marijuana.  In  colonial  America,  marijuana  was  a  major  commercial  crop  alongside  tobacco  and  was  grown  for  its 
fiber  much  like  cotton.  In  the  1920s,  the  recreational  use  of  marijuana  began  to  catch  on,  particularly  among 
entertainers.  Marijuana  use  at  this  time  was  not  illegal  and  was  not  considered  a  social  threat.  Between  the  mid- 19th 
and  20th  centuries,  marijuana  was  even  prescribed  for  various  medical  conditions  including  labor  pains,  nausea  and 
rheumatism.  In  the  1950s,  marijuana  use  became  increasingly  popular  and,  in  the  1960s,  it  became  a  symbol  of 
rebellion  against  authority.  In  the  Controlled  Substances  Act  of  1970,  the  federal  government  classified  marijuana 
along  with  heroin  and  LSD  as  a  Schedule  I  drug-having  the  highest  abuse  potential  and  no  accepted  medical  use- 
formalizing  its  illegality  and  highlighting  its  potential  for  addiction.  The  1980s  and  early  1990s  saw  the  passage  of 
strict  laws  and  mandatory  sentences  for  possession  of  marijuana  as  well  as  the  development  of  stronger  strains  of  the 
drug.149  In  recent  years,  a  growing  number  of  states  have  enacted  laws  bypassing  the  established  process  of  bringing 
drugs  to  market  in  the  U.S.  which  assures  safety  and  efficacy  and  permitting  the  use  of  marijuana  as  "medicine."150 

Opioids.  The  prescribing  and  dispensing  of  opioids  by  physicians  and  pharmacists  were  the  major  causes  of  the 
increase  in  narcotic  use  (and  addiction)  that  occurred  in  the  19th  century.151  Opium  and  morphine  were  believed  to 
cure  a  variety  of  health  conditions.152  At  the  turn  of  the  20th  century,  the  Bayer  Pharmaceutical  Company  promoted 
heroin  as  "the  sedative  for  coughs."153  At  this  time,  there  was  some  concern  about  the  "moral  degradation"  caused  by 
opioid  use,  but  drug  users  were  not  subject  to  legal  sanctions.154  Increased  concern  about  the  spread  of  opioid 
addiction  prompted  the  passage  of  several  Acts  restricting  the  use  and  distribution  of  narcotics  and  making  their  non- 
medical use  illegal.155  Since  that  time,  perceptions  of  narcotic/opioid  use  diverged  dramatically,  with  prescription 
opioids  marketed  as  beneficial  and  illegal  opioids  seen  as  a  scourge.  In  the  late  1990s,  the  growth  in  the  use  of 
prescribed  pain  relievers,  tranquilizers  and  stimulants  resulted  in  a  widespread  epidemic  of  prescription  drug  misuse 
and  addiction  among  people  of  all  ages,  which  now  pose  an  even  larger  addiction  problem  than  their  illegal 
counterparts.156  In  response,  efforts  to  control  this  misuse  have  led,  in  some  cases,  to  the  under-treatment  of  pain.157 


-28- 


Defining  the  Terms 

Part  of  the  problem  in  understanding  the  nature 
of  addiction  is  the  lack  of  precision  and 
uniformity  in  the  terms  used  to  describe  it  and 
distinguish  it  from  substance  use  that  threatens 
health  and  safety  but  is  not  addiction.158  Various 
terms  such  as  experimentation,  use,  misuse, 
risky  use,  hazardous  use,  excessive  use,  abuse, 
dependence  and  addiction  can  be  found  in  the 
research  literature  and  in  popular  parlance. 
There  are  no  standard  connotations  in  use  with 
regard  to  the  severity  of  the  behavior,  the 
consequences  of  the  behavior  or  the  ability  of 
the  individual  to  stop  the  behavior.  Nor  is  there 
recognition  that  the  severity  and  consequences 
of  different  levels  of  use  vary  considerably  by 
substance  and  with  the  age,  gender  and  health 
status  of  the  user. 

Further  confusion  can  be  found  in  the  misuse  of 
the  word  "treatment"  which  historically  has  been 
used  to  refer  to  a  host  of  interventions  including 
detoxification,  clinical  treatment  and 
professionally-administered  disease 
management,  social  and  mutual  support  and 
other  auxiliary  services.*  159  Rarely  has  the  term 
treatment  been  reserved  for  those  interventions 
that  are  based  in  the  clinical  and  scientific 
evidence,  as  it  is  for  the  treatment  of  other 
diseases. 

As  with  other  diseases,  precise  definitions  are 
essential  to  be  able  to  stage  the  disease  and 
develop  effective  interventions  and  treatments. 

The  Continuum  of  Substance  Use 

Substance  use  includes  smoking  or  otherwise 
ingesting  tobacco  products,  drinking  alcohol  or 


Detoxification  services  are  not  considered 
components  of  addiction  treatment;  rather,  they  are 
precursors  to  treatment  designed  to  manage  acute 
states  of  intoxication  or  withdrawal.  Social  and 
mutual  support  and  other  auxiliary  services  can  be 
critical  in  supporting  a  patient  through  treatment  and 
helping  over  the  long  term  to  sustain  advances 
achieved  through  clinical  treatment  and  to  avoid 
relapse. 


using  other  addictive  substances.   The  health 
consequences  of  use  of  these  substances  increase 
with  frequency  and  quantity  of  use.160  The 
continuum  of  use  ranges  from  no  use  on  one 
end,  to  use  that  does  not  involve  negative 
consequences,  to  risky  use-a  public  health 
problem,  to  addiction-a  medical  problem. 

Risky  Substance  Use:  A  Public  Health 
Problem.  Risky  substance  use  is  defined,  for 
the  purposes  of  this  report,  as  the  use  of  tobacco, 
alcohol  or  other  drugs  in  a  way  that  can  increase 
the  probability  of  harm  to  the  user  or  to  others 
but  does  not  meet  clinical  criteria  for  addiction* 
More  specifically,  it  includes  the  following 
(sometimes-overlapping)  categories: 

•  Use  of  any  addictive  substance  by  people 
under  the  age  of  21,  for  whom  there  is  no 
known  safe  level  of  use.§ 


1  Regardless  of  the  legal  status  of  the  substance. 
*  The  term  risky  use  was  chosen  to  reflect  a  range  of 
health  and  social  risks  inherent  in  the  use  of  these 
substances  and  to  underscore  the  fact  that  significant 
hazards  can  result  from  such  use  even  in  the  absence 
of  clinical  addiction.  See  Chapter  III  for  a  complete 
account  of  the  health  and  social  consequences  of  each 
of  the  following  types  of  substance  use  that  accounts 
for  their  designation  as  risky  substance  use  behaviors. 
§  Age  21  was  selected  because  of  the  cultural  marker 
of  adulthood  in  the  U.S.,  including  the  minimum 
legal  drinking  age,  although  research  documents  the 
continued  development  of  the  brain  (and  consequent 
vulnerability  to  the  effects  of  addictive  substances) 
into  the  mid-twenties. 


The  notion  of  critical  periods,  so  integral  to  the 
development  of  language  or  musical  skills,  is 
relevant  to  the  development  of  addiction  as 
well.  It  is  clear  from  my  work  in  addiction 
medicine  that  use  of  addictive  substances  is 
like  a  traumatic  brain  injury  to  a  young  person. 
Any  use  by  young  people  before  brain 
development  is  complete  equals  risky  use.161 

-Mark  S.  Gold,  MD 
University  of  Florida  College  of  Medicine  and 
McKnight  Brain  Institute 
Departments  of  Psychiatry,  Neuroscience, 
Anesthesiology,  Community  Health  & 
Family  Medicine 
Chairman,  Department  of  Psychiatry 


-29- 


•  Use  of  any  addictive  substance  by  pregnant 
women,  for  whom  there  is  no  known  safe 
level  of  use. 

•  Use  of  any  tobacco  product;  there  is  no 
known  safe  level  of  use  of  tobacco  products. 

•  Alcohol  use  in  excess  of  the  established 
dietary  guidelines  for  safe  alcohol  use  of  no 
more  than  one  drink  per  day  for  women  and 
two  drinks  per  day  for  men,  as  described  by 
the  U.S.  Departments  of  Agriculture 
(USDA)  Dietary  Guidelines.*  162  This 
includes  the  non-mutually  exclusive 
categories  of  binge  drinking,1  heavy 
drinking*  and  heavy  binge  drinking.5 

•  Misuse  (non-medical  use)  of  controlled 
prescription  drugs  and  over-the-counter 
medications**-i.e.,  using  them  for  purposes 


The  guidelines  also  stipulate  no  alcohol 
consumption  for:  (1)  persons  under  the  age  of  21;  (2) 
pregnant  women;  (3)  individuals  who  cannot  restrict 
their  drinking  to  moderate  levels;  (4)  individuals 
taking  prescription  or  over-the-counter  medications 
that  can  interact  with  alcohol;  (5)  individuals  with 
certain  specific  medical  conditions  (e.g.,  liver 
disease,  hypertriglyceridemia,  pancreatitis);  and  (6) 
individuals  who  plan  to  drive,  operate  machinery  or 
take  part  in  other  activities  that  require  attention,  skill 
or  coordination,  or  in  situations  where  impaired 
judgment  could  cause  injury  or  death  (e.g., 
swimming).  Although  drinking  alcohol,  as  described 
in  (4)  through  (6)  is  considered  risky  substance  use, 
estimates  of  rates  of  risky  substance  use  in  this  report 
do  not  include  these  criteria  since  they  are  not 
directly  measured  in  the  national  surveys  that  were 
analyzed  for  this  study. 
'  Consuming  five  or  more  drinks  on  the  same 
occasion  (within  a  few  hours)  on  at  least  one  day  in 
the  past  30  days. 

*  When  a  woman  consumes  more  than  three  drinks  on 
a  given  day  or  more  than  seven  drinks  during  a  given 
week  or  when  a  man  consumes  more  than  four  drinks 
on  a  given  day  or  more  than  14  drinks  during  a  given 
week. 

§  Binge  drinking  on  at  least  five  occasions  in  the  past 
30  days. 

**  In  accordance  with  the  federal  Controlled 
Substances  Act  of  1970  which  created  a  system  for 
classifying  illicit  and  prescription  drugs  according  to 
their  medical  value  and  their  potential  for  misuse. 


not  prescribed  or  intended  such  as  to  get 
high,  feel  stimulated  or  sedated;  taking  more 
of  the  substance  than  prescribed  or 
recommended;  or  taking  the  substance  too 
often  or  for  a  longer  period  of  time  than  was 
prescribed  or  recommended. ft  163 

•    Use  of  non-prescribed  federally  controlled 
(illegal/illicit  drugs)  drugs;K  there  is  no 
known  safe  level  of  use  of  these  drugs. 


Addiction:  A  Medical  Disease.  At  the  end  of 

the  continuum  of  substance  use  are  those  who 
meet  clinical  criteria  for  addiction.  Yet  even 
among  these  individuals,  there  is  tremendous 
variation  in  the  severity  and  course  of  the 
disease.  At  the  extreme  end  of  the  continuum  is 


TT  For  data  analysis  purposes,  the  national  survey 
examined  for  this  report  defines  misuse  of  controlled 
prescription  medications  more  generally  as  "taking  a 
controlled  prescription  drug  not  prescribed  for  you  or 
taking  it  in  a  manner  not  prescribed  for  the 
experience  or  feeling  it  causes."  The  misuse  of  over- 
the-counter  medications  also  constitutes  risky  use; 
however,  rates  of  risky  substance  use  in  this  report  do 
not  include  the  misuse  of  these  medications  since 
they  are  not  directly  measured  in  the  national  surveys 
that  were  analyzed  for  this  study. 
M  Substances  controlled  (either  through  prohibited  or 
restricted  use)  by  the  federal  Controlled  Substances 
Act  of  1970  which  created  a  system  for  classifying 
illicit  and  prescription  drugs  according  to  their 
medical  value  and  their  potential  for  misuse.  In  the 
analyses  presented  in  this  report,  illicit  drugs  include 
marijuana/hashish,  cocaine/crack,  heroin, 
hallucinogens,  Ecstasy,  methamphetamine  and 
inhalants.  (See  Chapter  III.) 


The  public,  and  treatment  sources  alike,  often  are 
confused  as  to  the  distinction  among  use,  heavy 
use  and  addictive  disease. 164 

-Stuart  Gitlow,  MD,  MPH,  MBA 
Executive  Director 
Annenberg  Physician  Training  Program  in 
Addictive  Disease 
Associate  Clinical  Professor 
Mount  Sinai  School  of  Medicine 
Acting  President  &  AMA  Delegate 
American  Society  of  Addiction  Medicine 


-30- 


the  most  severe  form  of  the  illness:  chronic 
relapsing  disease. 

There  are  two  leading  sources  of  diagnostic 
classifications  for  addiction  (called  substance 
use  disorders):  The  American  Psychiatric 
Association's  Diagnostic  and  Statistical  Manual 
of  Mental  Disorders  (DSM-IV)  and  the  World 
Health  Organization's  International  Statistical 
Classification  of  Disease  (ICD).  Both  reflect  the 
historical  classification  of  addiction  as  a  mental 
disorder  based  on  measures  of  its  behavioral 
symptoms  rather  than  the  current  science 
documenting  the  medical  nature  of  the  problem 
as  an  underlying  brain  disease.166 

Diagnostic  and  Statistical  Manual  of  Mental 
Disorders  (DSM-IV).  The  DSM-IV  is  the  main 
diagnostic  reference  of  mental  health 
professionals  in  the  United  States  and  presents 
three  types  of  disorders  that  are  drug  specific: 
(1)  alcohol  use  disorders,  (2)  drug  use  disorders 
and  (3)  nicotine  dependence.  Both  alcohol  and 
drug  use  disorders  involve  two  levels  of 
severity— abuse  and  dependence— while  nicotine 
only  involves  dependence.  The  criteria  for 
abuse  are  similar  for  alcohol  and  other  drugs, 
and  the  criteria  for  dependence  are  similar  for  all 
three  drug  types.167 

The  DSM-IV  defines  substance  abuse  as  "a 
maladaptive  pattern  of  substance  use  leading  to 
clinically  significant  impairment  or  distress."168 
The  term  substance  abuse,  though  widely  used- 
and  often  used  beyond  its  clinical  definition  to 
describe  any  kind  of  risky  substance  use-has 
become  controversial  due  to  its  negative,  value- 
laden  and  pejorative  connotation.169 

The  term  substance  dependence  is  defined  in  the 
DSM-IV  as  ". .  .a  cluster  of  cognitive,  behavioral 
and  physiological  symptoms  indicating  that  the 
individual  continues  use  of  the  substance  despite 
significant  substance-related  problems."170 


DSM-IV  Criteria165 
Substance  Abuse 

To  be  diagnosed  with  substance  abuse,  an  individual 
must  exhibit  one  or  more  of  the  following  four 
symptoms  within  a  12-month  period:* 

•  Recurrent  use  resulting  in  failure  to  fulfill  major 
role  obligations  at  work,  school  or  home; 

•  Recurrent  use  in  physically  hazardous 
situations; 

•  Recurrent  use  resulting  in  legal  problems;  and 

•  Continued  use  despite  persistent  or  recurrent 
social  or  interpersonal  problems. 

Substance  Dependence 

To  be  diagnosed  with  substance  dependence,  an 
individual  must  exhibit  three  or  more  of  seven 
symptoms  within  a  12-month  period: 

•  Tolerance— the  need  for  markedly  increased 
amounts  of  the  substance  to  achieve  intoxication 
or  the  desired  effect  or  a  markedly  diminished 
effect  with  the  continued  use  of  the  same 
amount  of  the  substance; 

•  Withdrawal-maladaptive  behavioral  change 
with  co-occurring  physiological  and  cognitive 
changes  that  occurs  when  use  of  a  substance  is 
reduced  or  discontinued,  or  usage  of  a  substance 
to  relieve  or  avoid  withdrawal  symptoms; 

•  Taking  increasing  amounts  or  using  the 
substance  over  a  longer  period  than  intended; 

•  A  persistent  desire  or  unsuccessful  efforts  to 
reduce  or  control  substance  use; 

•  Spending  a  significant  amount  of  time  in 
activities  to  obtain  the  drug,  use  it  or  recover 
from  use; 

•  Neglecting  or  giving  up  important  social, 
occupational  or  recreational  activities  because  of 
use;  and 

•  Continuing  use  of  the  substance  despite 
knowledge  of  having  a  persistent  or  recurring 
physical  or  psychological  problem  that  is  caused 
or  worsened  by  use. 


*  The  symptoms  must  never  have  met  criteria  for 
substance  dependence  for  the  class  of  substances 
used. 


-31- 


Definitional  Problems.  The  first  two  symptoms 
of  the  DSM-IV's  substance  dependence 
diagnosis-tolerance  and  withdrawal—  reflect 
physiological  dependence  on  a  substance  as  a 
result  of  its  regular  use.171  There  has  been 
considerable  confusion  about  the  difference 
between  physiological  dependence  on  a 
substance  and  addiction  involving  that 
substance.  This  is  further  confused  by  the  use  of 
the  same  term  "dependence"  to  apply  to  both 
conditions. 

According  to  the  DSM-IV  diagnostic  criteria, 
tolerance  and  withdrawal  symptoms  neither  are 
necessary  nor  sufficient  for  a  diagnosis  of 
substance  dependence112  (e.g.,  an  individual  may 
meet  diagnostic  criteria  for  addiction  involving 
cocaine  or  methamphetamine  in  the  absence  of 
symptoms  of  tolerance  and  withdrawal).173 
There  also  are  cases  where  an  individual  is 
physically  dependent  on  a  substance  but  does 
not  meet  clinical  criteria  for  addiction.174  This 
occurs  relatively  frequently  in  relation  to  the  use 
of  controlled  prescription  pain  relievers. 
Prolonged  use  of  these  medications  may  result  in 
physical  symptoms,  including  tolerance  and 
withdrawal  as  a  result  of  the  body's  adaptation 
to  taking  the  drug,175  but  may  not  include  the 
loss  of  control  and  other  behavioral  symptoms 
associated  with  addiction.176 

Other  symptoms  of  substance  dependence  also 
can  be  observed  in  patients  legitimately  using 
certain  prescription  medications.177  For 
example,  if  a  patient's  pain  is  under- treated,  he 
or  she  may  become  preoccupied  with  finding  a 
pain  medication  or  may  take  a  pain  medication 
for  a  longer  time  than  originally  was 
prescribed.178  Mischaracterizing  this  behavior  as 
addiction  may  result  in  further  withholding  of 
legitimate  pain  treatment/  179 

Issues  have  been  raised  with  regard  to  the 
reliability  and  validity  of  the  nicotine 


Opioids. 

f  While  the  under-treatment  of  pain  has  been 
acknowledged,  there  are  emerging  indications  that 
many  physicians  may  now  be  overprescribing 
addictive  opioid  medications  for  the  treatment  of 
patients  with  non-malignant  chronic  pain. 


dependence  criteria  as  well:  they  have  been 
described  as  ambiguous,  failing  to  address 
important  aspects  of  addiction  involving  nicotine 
such  as  craving,  too  subjective  and  intertwined 
with  an  individual's  social  context  (e.g.,  with 
regard  to  assessing  the  "costs"  of  continued  use) 
and  limited  in  their  ability  to  predict  key 
outcomes  such  as  extent  of  tobacco  use, 
withdrawal  severity  and  likelihood  of  future 
cessation.180 

Proposed  Modifications  to  the  DSM  Diagnostic 
Criteria.  Partially  because  of  these  definitional 
problems,  work  is  under  way  to  redefine  and 
reorganize  the  DSM's  diagnostic  criteria  for 
substance  use  disorders.  These  revisions  are 
proposed  to  be  included  in  the  upcoming  DSM- 
V  version,  which  is  estimated  to  be  released  in 
May  20 13. 181  Among  the  proposed  revisions  is 
the  suggestion  to  replace  the  two  categories  of 
substance  abuse  and  substance  dependence  with 
a  single  diagnostic  category  of  substance  use 
and  addictive  disorders}  182  This  modification 
recognizes  a  broad  category  of  addiction 
including  substance  addiction  and  other 
compulsive  behaviors  that  reflect  a  common 
neuropathology.183  Separate  disorders  would  be 
identified  for  each  type  of  addictive  substance  or 
behavior  and  for  multiple  addictive  disorders. 
The  addictive  disorder  diagnosis  would  contain 
1 1  criteria;  meeting  two  or  three  criteria  would 
result  in  a  diagnosis  of  "moderate"  severity, 
while  meeting  four  or  more  criteria  would  result 
in  a  diagnosis  of  "severe."  The  presence  of 
physical  dependence  (symptoms  of  tolerance  or 
withdrawal)  also  would  be  identified. §  184 


1  Initially,  the  Substance-Related  Disorders  Work 
Group  for  the  revisions  to  the  DSM  considering 
renaming  this  category  "Addiction  and  Related 
Disorders." 

§  The  proposed  revised  criteria  clearly  state  that 
tolerance  and  withdrawal  are  "not  counted  for  those 
taking  medications  under  medical  supervision  such  as 
analgesics,  antidepressants,  anti-anxiety  medications 
or  beta-blockers."  This  stipulation  is  designed  to 
prevent  a  patient  who  becomes  physically  dependent 
on  a  prescription  drug  received  during  the  course  of 
medical  care  from  being  diagnosed  with  addiction 
(i.e.,  a  substance  use  disorder). 


-32- 


One  issue  being  raised  in  the  proposed  revisions 
to  the  DSM  is  that  of  patients  who  are  at 
heightened  risk  of  developing  addiction  in  the 
near  future  but  do  not  now  meet  the  diagnostic 
criteria.185  One  suggestion*  is  to  add  a  severity 
category  of  "mild"  to  the  proposed  "moderate" 
and  "severe"  diagnosis  categories.  This 
modification  would  help  to  identify  risky 
substance  users  and  increase  the  chances  that 
they  receive  needed  services  to  prevent  their 
risky  use  from  progressing  to  addiction,  while 
reducing  the  risk  of  their  receiving  unnecessary 
treatment  which  might  accompany  a  more 
severe  diagnosis.186 

International  Statistical  Classification  of 
Diseases  (ICD).  Like  the  DSM,  the  ICD  does 
not  present  a  disease  category  of  addiction; 
rather,  it  presents  mental  health  disorders  that 
are  linked  to  psychoactive  substance  use 
including  nicotine,  alcohol  and  other  drugs.187 

Like  the  DSM,  the  ICD  offers  two  categories 
related  to  addiction:  in  this  case,  harmful  use 
and  dependence  syndrome.  Harmful  use  is 
defined  as  "a  pattern  of  psychoactive  substance 
use  that  is  causing  damage  to  health.  The 
damage  may  be  physical  (e.g.,  hepatitis 
following  injection  of  drugs)  or  mental  (e.g., 
depressive  episodes  secondary  to  heavy  alcohol 
intake)."  The  ICD  defines  dependence 
syndrome  as  "a  cluster  of  behavioral,  cognitive 
and  physiological  phenomena  that  may  develop 
after  repeated  substance  use.  Typically,  these 
phenomena  include  a  strong  desire  to  take  the 
drug,  impaired  control  over  its  use,  persistent 
use  despite  harmful  consequences,  a  higher 
priority  given  to  drug  use  than  to  other  activities 
and  obligations,  increased  tolerance  and  a 
physical  withdrawal  reaction  when  drug  use  is 
discontinued."188 

The  DSM  vs.  the  ICD.  While  there  is 
considerable  overlap  between  the  diagnostic 
definitions  provided  in  the  DSM  and  the  ICD, 
the  ICD  definitions  connote  more  of  a  disease 
state  while  the  DSM  definitions  imply  more  of  a 
behavioral  disorder.  In  addition,  the  ICD  is  used 


Made  by  NAADAC,  the  Association  for  Addiction 
Professionals. 


more  frequently  internationally  while  the  DSM 
is  used  more  frequently  in  the  United  States  and 
Canada.189  Access  to  the  ICD  codes  is  free  to 
the  public  via  the  Internet,  whereas  providers 
must  pay  the  American  Psychiatric  Association 
for  access  to  the  DSM  manual  and  codes,  either 
by  purchasing  the  text  version  of  the  manual  or 
by  paying  to  access  the  information  online.190 
The  DSM  is  used  more  commonly  than  the  ICD 
in  research  studies,  whereas  the  ICD  has  become 
the  primary  tool  used  by  health  care  facilities  to 
index  health  care  data.191  The  DSM  criteria  for 
addiction  involving  nicotine  are  used  less 
frequently  by  researchers  and  clinicians  than 
criteria  for  addiction  involving  alcohol  and  other 
drugs;  192 

Like  the  DSM,  the  ICD  currently  is  undergoing 
revisions  and  there  is  hope  that  the  parties 
involved  in  the  revisions  to  these  classification 
systems  will  take  the  opportunity  to  standardize 
the  language  used  to  describe  the  full  spectrum 
of  clinical  addiction,193  with  an  increased  focus 
on  the  disease  itself  rather  than  different 
disorders  linked  to  specific  substances. 

It  also  is  important  to  clarify  that  addiction  is  a 
medical  condition  with  significant  behavioral 
components.194  Recognizing  that  current 
diagnostic  classification  systems  like  the  DSM 
and  ICD  do  not  sufficiently  take  into  account  the 
shared  underlying  genetic  and  neurobiological 
dimensions  of  addiction  and  various  health 
conditions— instead  relying  primarily  on 
subjective  reports  of  symptoms  of  seemingly 
unique  and  unitary  conditions-the  National 
Institute  of  Mental  Health  (NIMH)  has  begun  to 
classify  these  conditions  in  a  new  way.  The 
Research  Domain  Criteria  project  (RDoC)  aims 
to  develop  a  classification  system  based  on 
observable  behavior  and  neurobiological 
measures  that  underlie  different  manifestations 
of  addiction  and  related  conditions  which 
currently  are  classified  and  addressed  as  distinct 
conditions.195  Should  this  new  system  take  hold, 


1  Measures  of  addiction  involving  nicotine  that  are 
considered  to  have  greater  predictive  validity  in  terms 
of  outcomes  include  the  Fagerstrom  Test  for  Nicotine 
Dependence  (TTND)  and  Nicotine  Dependence 
Symptom  Scale  (NDSS). 


-33- 


it  eventually  may  help  practitioners  diagnose 
and  address  the  disease  of  addiction  and  its 
multiple  manifestations  in  a  more  unified  and 
coherent  manner  in  clinical  practice. 

Public  Attitudes  about  Addiction 

Public  attitudes  about  a  particular  disease  or 
health  condition  and  the  people  who  suffer  from 
it  historically  have  been  linked  to  the  public's 
understanding  of  its  causes  and  amenability  to 
treatment.  This  nation  has  a  long  history  of 
isolating  and  stigmatizing  individuals  with 
health  problems  that  were  not  well  understood, 
from  tuberculosis  to  cancer,  depression  and 
HIV-AIDS.  Once  scientific  understanding  of 
the  condition  is  solidified  and  the  information 
permeates  public  understanding,  public  attitudes 
towards  the  condition  and  those  who  have  it 
often  change.  The  availability  of  effective 
treatments  also  can  have  a  profound  impact  on 
driving  this  change.  Addiction  is  a  prime 
example  of  a  disease  where  public  attitudes  have 
yet  to  catch  up  with  the  science,  although 
attitudes  are  shifting.196 

A  2005  online  survey  of  1,000  adults  ages  20 
and  older  about  addiction  involving  alcohol 
found  that  63  percent  of  the  general  public  see  it 
primarily  as  a  personal  or  moral  weakness  ( 1 9 
percent)  or  equally  as  a  personal  or  moral 
weakness  and  as  a  disease  or  health  problem  (44 
percent);  only  34  percent  see  it  primarily  as  a 
disease  or  health  problem.  In  contrast,  only  1 1 
percent  of  individuals  who  are  managing  the 
disease  (i.e.,  in  recovery)  see  it  either  primarily 
as  a  personal  or  moral  weakness  (two  percent)  or 
as  both  a  personal  or  moral  weakness  and  a 
disease  or  health  problem  (nine  percent);  81 
percent  see  it  primarily  as  a  disease  or  health 
problem.  This  survey  also  found  that  43  percent 
of  physicians  consider  addiction  involving 
alcohol  to  be  a  personal  or  moral  weakness  (nine 
percent  see  it  primarily  as  a  personal  or  moral 
weakness  and  34  percent  see  it  equally  as  a 
personal  or  moral  weakness  and  as  a  disease  or 
health  problem);  56  percent  see  it  primarily  as  a 
disease  or  health  problem.197 


A  more  recent  survey  of  treatment  providers  in 
the  U.S.  and  the  United  Kingdom,  published  in 
201 1,  found  that  the  belief  that  addiction  is  a 
disease  is  stronger  among  those  who  provide 
for-profit  treatment  while  the  belief  that 
addiction  is  a  choice  is  stronger  among  providers 
of  public  or  not-for-profit  treatment*  198— the 
more  common  form  of  treatment  in  the  United 
States.199 

Results  from  a  nationally  representative  survey 
conducted  in  2008  found  that  44  percent  of  the 
public  believes  that  people  with  addiction 
involving  alcohol  could  stop  drinking  if  they 
had  enough  willpower  (73  percent  of  young 
adults,  age  18  to  24,  hold  this  view).  Fewer 
Americans  think  the  same  is  true  for  addiction 
involving  other  drugs  (38  percent  of  the  public; 
66  percent  of  young  adults).200 


A  2009  nationally  representative  survey  of  1 ,000 
adults  ages  1 8  and  older  underscores  the 
tremendous  stigma  still  associated  with 
addiction:  individuals  with  addiction  involving 
alcohol  or  other  drugs  commonly  were  described 
by  respondents  with  words  such  as  "sinner," 
"irresponsible,"  "selfish,"  "stupid,"  "loser," 
"undisciplined,"  "pathetic"  and  "weak."202 


Differences  also  were  found  between  providers  who 
were  members  of  a  group  of  addiction  professionals, 
had  been  treating  addiction  for  longer,  had  stronger 
spiritual  beliefs,  had  a  past  addiction  problem  and 
were  older  (tending  to  endorse  the  belief  that 
addiction  is  a  disease)  versus  those  who  were  not 
members  of  a  group  of  addiction  professionals,  had 
less  strong  spiritual  beliefs  and  were  younger 
(tending  to  endorse  the  belief  that  addiction  is  a 
choice). 


The  average  person  in  the  U.S.  views  addiction 
with  a  sense  of  hopelessness.  They  realize  that 
not  all  users  of  alcohol  or  other  addictive  drugs 
will  become  addicted.  They  know  that  some 
users  will  become  addicted  but  that  others  will 
not.  This  creates  a  belief  that  the  addict  can— 
and  should— use  willpower  to  stop  using.101 

-  J.  Paul  Molloy,  JD 
Chief  Executive  Officer 
Oxford  House 


-34- 


However,  as  a  sign  of  increasing  acceptance  of 
addiction  as  a  disease,  this  same  survey  found 
that  the  majority  (78  percent)  regard  addiction 
involving  drugs  other  than  nicotine  or  alcohol  as 
a  chronic  disease.203  Another  2009  nationally 
representative  survey  of  adults  ages  1 8  and  older 
also  found  that  the  majority  of  the  respondents 
believe  that  addiction  is  a  health  condition  that 
requires  ongoing  attention  and  support  (83 
percent).204 

Perceived  Causes  of  Addiction 

For  decades,  public  misconceptions  about  the 
origins  of  addiction  have  led  to  negative 
attitudes  and  discrimination  against  those 
afflicted  with  the  disease  and  hindered  progress 
not  only  in  understanding  it,  but  also  in 
developing  and  providing  effective  treatments 
for  it.205  In  2008,  CASA  Columbia  probed  these 
perspectives  with  a  nationally  representative 
survey  of  American  attitudes  toward  substance 
use  and  addiction— the  National  Addiction  Belief 
and  Attitude  Survey  (NABAS).  Although  public 
attitudes  increasingly  appear  to  be  reflective  of 
the  science  of  addiction,  people  still  often  hold 
conflicting  views  about  the  causes  of  addiction, 
many  of  which  are  inconsistent  with  the  growing 
body  of  evidence. 

CASA  Columbia's  NABAS  found,  for  example, 
that  while  many  people  understand  that  factors 
such  as  genetics,  family  history,  other  health 
problems  and  availability  of  addictive 
substances  play  a  role  in  the  development  of 
addiction  and  that  loss  of  control  is  a  defining 
characteristic  of  the  disease,  a  significant 
proportion  of  Americans  cite  "lack  of  will  power 
or  self-control"  as  a  primary  causal  factor. 
Surprisingly,  respondents  who  had  a  personal 
experience  with  addiction— either  that  of  a 
family  member  or  friend  or  their  own— did  not 
differ  much  from  the  general  public  in  these 
perceptions  of  the  key  contributors  to  addiction. 
Respondents  also  had  different  views  on  the 
causes  of  addiction  depending  on  the  substance 
involved.206 


Tobacco/Nicotine.  Despite  the  fact  that 
genetics  account  for  up  to  75  percent  of  the  risk 
for  addiction  involving  nicotine,207  the  NABAS 
found  that  only  one  in  four  respondents  (25.4 
percent)  cited  "a  predisposition  to  addiction,  due 
to  genetics  or  family  history"  as  a  primary 
causal  factor  when  given  a  list  of  potential 
causes  of  addiction  involving  tobacco/nicotine. 
Respondents  were  most  likely  to  cite  an 
"inability  to  resist  peer  pressure"  (43.5  percent); 
"easy  availability  of  tobacco  among  youth" 
(38.7  percent);  "stress  or  anxiety  about  work, 
family  or  other  problems"  (37.7  percent);  and 
"lack  of  willpower  or  self-control"  (33.0 
percent)  as  primary  causal  factors.208 
(Figure  2. A) 


Figure  2.A 

Perceived  Causes  of  Addiction 
Involving  Tobacco/Nicotine 

Inability  To  Resist  Peer  Pressure 

P 
E 
R 

C 

Easy  Availability 

I  38.7 

Stress/Anxiety 

|  37.7 

E 

N 

Lack  of  Willpower/Self-Control 

|  33.0 

T 

Predisposition/Genetics/ 
Family  History 

Source:  CASA  Columbia  National  Addiction  Belief  and  Attitude 
Survey  (NABAS),  2008. 

Note  1 :  Respondents  could  choose  two  or  three  answers. 

Note  2:  Other  research  finds  that  genetics  account  for  up  to  75%  of 

the  risk  of  nicotine  dependence. 

Alcohol.  Public  attitudes  are  more  aligned  with 
the  science  regarding  the  role  of  genetics  in 
addiction  involving  alcohol.  Genetics  account 
for  48  to  66  percent  of  the  risk  that  someone 
who  drinks  alcohol  will  become  addicted209  and 
nearly  half  (47.6  percent)  of  respondents  to  the 
NABAS  cite  "a  predisposition  to  addiction,  due 
to  genetics  or  family  history"  as  a  primary 
causal  factor.  Other  perceived  primary  causes  of 
addiction  involving  alcohol  include  "stress  or 
anxiety  about  work,  family  or  other  problems" 
(44.9  percent);  "emotional  disorders  or  mental 
illness,  such  as  depression  or  anxiety"  (35.3 
percent);  "lack  of  willpower  or  self-control" 


-35- 


(29.7  percent);  "easy  availability  of  alcohol 
among  youth"  (29.2  percent);  and  "inability 
to  resist  peer  pressure"  (28.2  percent).210 
(Figure  2.B) 

Other  Drugs.  Although  genetic  factors 
account  for  up  to  78  percent  of  the  risk  for 
developing  addiction  involving  illegal  or 
controlled  prescription  drugs  (depending  on 
the  type  of  drug  studied  and  the  severity  of 
the  addiction),211  only  27.5  percent  of 
NABAS  respondents  cited  "a  predisposition 
to  addiction,  due  to  genetics  or  family 
history"  as  a  primary  cause  of  addiction 
involving  prescription  drugs.  The  most 
commonly  cited  factor  that  may  cause  people 
to  become  addicted  to  prescription  drugs  was 
"emotional  disorders  or  mental  illness,  such 
as  depression  or  anxiety"  (40.8  percent).212 
Co-occurring  mental  health  disorders  do 
appear  to  play  a  significant  role  in  the  risk  that 
drug  use  will  progress  to  addiction.213  Other 
primary  causes  that  were  mentioned  by 
respondents  to  the  NABAS  include  "stress  or 
anxiety  about  work,  family  or  other 
problems"  (36.9  percent);  "easy  availability 
of  prescription  medications  among  youth" 
(36.7  percent);  and  a  "lack  of  willpower  or 
self-control"  (26.9  percent).214  (Figure  2.C) 

Thirty  percent  cited  "a  predisposition  to 
addiction,  due  to  genetics  or  family  history" 
as  a  primary  cause  of  addiction  involving 
illegal  drugs.  The  most  commonly  cited 
factor  that  may  cause  people  to  become 
addicted  to  illegal  drugs  was  an  "inability  to 
resist  peer  pressure"  (41.9  percent).  Other 
factors  that  were  mentioned  as  a  primary 
cause  of  addiction  involving  illicit  drugs 
include  "easy  availability  of  illegal  drugs 
among  youth"  (35.1  percent);  "emotional 
disorders  or  mental  illness,  such  as  depression  or 
anxiety"  (34.8  percent);  "stress  or  anxiety  about 
work,  family  or  other  problems"  (29.9  percent); 
and  a  "lack  of  willpower  or  self-control"  (28.7 
percent).215  (Figure  2.D) 


Figure  2.B 

Perceived  Causes  of  Addiction 
Involving  Alcohol 


Predisposition/Genetics/ 
Family  History 

Stress/Anxiety 
Emotional  Disorders/Mental  Illness 
Lack  of  Willpower/Self-Control 
Easy  Availability 
Inability  to  Resist  Peer  Pressure 


□  47.6 


3  44.9 


35.3 


|  29.7 
|  29.2 
28.2 


Source:  CASA  Columbia  National  Addiction  Belief  and  Attitude 
Survey  (NABAS),  2008. 

Note  1 :  Respondents  could  choose  two  or  three  answers. 
Note  2:  Other  research  finds  that  genetics  account  for  48%  to  66% 
of  the  risk  that  someone  who  drinks  alcohol  will  develop  an  addiction 
involving  alcohol. 


Figure  2.C 

Perceived  Causes  of  Addiction 
Involving  Controlled  Prescription  Drugs 

Emotional  Disorders/Mental  Illness 

|  40.8 

P 

Stress/Anxiety 

|  36.9 

E 

R 

Easy  Availability 

|  36.7 

C 

Predisposition/Genetics/ 
Family  History 

E 
N 

|  27.5 

T 

Lack  of  Willpower/Self-Control 

 |  26.9 

Source:  CASA  Columbia  National  Addiction  Belief  and  Attitude  Survey 
(NABAS),  2008. 

Note  1 :  Respondents  could  choose  two  or  three  answers. 

Note  2:  Other  research  finds  that  genetics  account  for  up  to  78%  of  the  risk  for 

the  development  of  addiction  involving  prescription  and  other  drugs. 

-36- 


Figure  2.D 

Perceived  Causes  of  Addiction 
Involving  Illegal  Drugs 


Inability  To  Resist  Peer  Pressure 
Easy  Availability 
Emotional  Disorders/Mental  Illness 

Stress/ Anxiety 

Predisposition/Genetics/ 
Family  History 

Lack  of  Willpower/Self-Control 


Source:  CASA  Columbia  National  Addiction  Belief  and  Attitude  Survey 
(NABAS),  2008. 

Note  1 :  Respondents  could  choose  two  or  three  answers. 

Note  2:  Other  research  finds  that  genetics  account  for  up  to  78%  of  the 

risk  for  the  development  of  addiction  involving  prescription  and  other 

drugs. 


The  NABAS  found  little  indication  that 
respondents  attribute  addiction  primarily  to  an 
"absence  of  religious  faith  or  spiritual 
grounding"  or  to  "distorted  moral  values."216 


-37- 


-38- 


Chapter  III 

Prevalence  and  Consequences 


More  than  one  in  seven  (15.9  percent,  40.3 
million)  people  in  the  United  States  ages  12  and 
older  currently  meet  clinical  criteria  for 
addiction*  '--more  than  the  share  of  the 
population  with  cancer,  diabetes  or  heart 
disease. '  2  An  additional  but  unknown  number 
of  people  have  the  disease  but  are  managing  it 
effectively  and  so  do  not  meet  these  behavioral 
criteria. 1 3  Another  third  of  the  population  (31.7 
percent,  80.4  million),  while  not  addicted, 
currently5  use  one  or  more  addictive  substances 
in  ways  that  threaten  their  own  health  and  safety 
or  the  health  and  safety  of  others.4 

Risky  substance  use  and  addiction  are  the  largest 
preventable  and  most  costly  public  health  and 
medical  problems  in  the  U.S.5  Together  they  are 
the  leading  causes  of  preventable  death  and 
cause  or  contribute  to  more  than  70  other 
conditions  requiring  medical  care.6  The 
damaging  effects  of  risky  substance  use  and 
addiction  extend  to  a  wide  range  of  costly  social 


Defined  as  meeting  criteria  for  past-month  nicotine 
dependence  based  on  the  Nicotine  Dependence 
Syndrome  Scale  (NDSS)  and  meeting  diagnostic 
criteria  for  past  year  alcohol  and/or  other  drug  abuse 
or  dependence  (excluding  nicotine)  in  accordance 
with  the  Diagnostic  and  Statistical  Manual  of  Mental 
Disorders  (DSM-IV).  (The  DSM  refers  to  substance 
abuse  and  substance  dependence  collectively  as 
substance  use  disorders.  The  criteria  for  nicotine 
dependence  in  the  NDSS  parallel  those  of  the  DSM- 
IV.)  This  estimate  excludes  the  institutionalized 
population,  for  which  rates  of  addiction  are  higher. 
f  Includes  coronary  heart  disease,  angina  pectoris, 
heart  attack  or  any  other  heart  condition  or  disease, 
excluding  hypertension  and  stroke. 
*  There  are  no  national  data  on  the  proportion  of  the 
population  that  has  been  diagnosed  with  addiction 
and  is  effectively  managing  the  disease.  Existing 
national  survey  data  indicate  that  10  percent  of  adults 
ages  1 8  and  older  report  that  they  "once  had  a 
problem  with  drugs  or  alcohol  but  no  longer  do" 
(sometimes  referred  to  as  "sustained  recovery"),  but 
it  is  not  clear  what  proportion  of  this  group  ever  was 
diagnosed  with  addiction  as  distinguished  from 
"having  a  problem." 
§  In  the  past  30  days. 


-39- 


consequences  including  crime,  lost  productivity, 
child  neglect  and  abuse,  family  dysfunction  and 
developmental  disabilities. 

Certain  populations-including  pregnant  women, 
adolescents  and  young  adults  and  the  elderly- 
are  more  vulnerable  to  the  damaging  effects  of 
addictive  substances.  Other  populations- 
including  those  with  co-occurring  disorders, 
members  of  the  military  exposed  to  combat  and 
those  in  the  justice  system— are  more  likely  to 
engage  in  risky  use  or  have  addiction. 

Defining  the  Problem 

Substance  use  can  be  understood  as  a  continuum 
ranging  from  having  never  smoked  or  used 
alcohol  or  another  drug  at  one  end  to  having  an 
unmanaged  chronic,  relapsing  diseasef  at  the 
other.  (Figure  3. A) 


Figure  3. A 

Continuum  of  Substance  Use 

Percent  of  Population  Age  12+ 
by  Level  of  Sustance  Use* 


12.7 

25.2 

14.5 



31.7 

Never 
Used 

No 
Current 
Use 

Non- 
Risky  Use 

Risky 
Use 

15.9 

Addiction 


*  Includes  tobacco,  alcohol,  illicit  drugs  and  misuse  of 
controlled  prescription  drugs. 

Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  2010. 


Most  people  (87.3  percent)  ages  12  and  older  in 
the  U.S.  have  used  one  or  more  addictive 


Including  any  use  of  illicit  drugs  or  the  misuse  of 
controlled  prescription  drugs. 
'  This  continuum  focuses  on  substance  use;  the 
category  labeled  addiction  includes  those  individuals 
whose  substance  use  meets  current  clinical  criteria 
for  this  disease  but  does  not  include  all  individuals 
with  addiction.  There  are  some  individuals  with  the 
disease  of  addiction  who  do  not  currently  use  any 
addictive  substances  and  others  who  currently  may  fit 
into  other  use  categories  along  the  continuum. 


substances  at  some  point  in  their  lives,  and  62. 1 
percent  are  current  users.1 7  Those  who  have 
never  used  an  addictive  substance,  are  not 
current  users5  or  do  not  engage  in  risky 
substance  use  are  appropriate  targets  for  public 
health  efforts  aimed  at  preventing  risky  use  and 
addiction;  however,  these  individuals  are  not  the 
focus  of  this  report. 

While  this  report  focuses  primarily  on  those  with 
the  disease  of  addiction,  it  makes  an  important 
distinction  between  addiction  and  risky  use  of 
addictive  substances: 

•  Those  with  the  disease  of  addiction  are 
defined  in  this  report  as  meeting  the  clinical 
diagnostic  criteria  for  past  month  nicotine 
dependence  or  past  year  alcohol  and/or  other 
drug  abuse  or  dependence.  Individuals  who 
meet  diagnostic  criteria  for  addiction  are 
targets  for  appropriate,  evidence-based 
clinical  interventions  by  physicians  and 
other  health  professionals. 

•  Risky  users  of  addictive  substances  are 
defined  in  this  report  as  those  who  currently 
use  tobacco  products,  exceed  the  U.S. 
Department  of  Agriculture  (USDA)  Dietary 
Guidelines  for  safe  alcohol  use,** 8 


1  Current  substance  use  among  the  entire  U.S. 
population  ages  12  and  older:  51.7  percent  drink 
alcohol;  27.6  percent  use  tobacco  products;  7.5 
percent  use  illicit  drugs;  and  2.8  percent  misuse 
controlled  prescription  drugs. 
§  Having  used  the  substance  in  the  past  30  days. 

The  U.S.  Department  of  Agriculture  Dietary 
Guidelines  for  safe  alcohol  use  are  no  more  than  one 
drink  a  day  for  women,  no  more  than  two  drinks  a 
day  for  men  and  no  alcohol  consumption  for: 
(1)  persons  under  the  age  of  21;  (2)  pregnant  women; 
(3)  individuals  who  cannot  restrict  their  drinking  to 
moderate  levels;  (4)  individuals  taking  prescription  or 
over-the-counter  medications  that  can  interact  with 
alcohol;  (5)  individuals  with  certain  specific  medical 
conditions  (e.g.,  liver  disease,  hypertriglyceridemia, 
pancreatitis);  and  (6)  individuals  who  plan  to  drive, 
operate  machinery  or  take  part  in  other  activities  that 
require  attention,  skill  or  coordination  or  in  situations 
where  impaired  judgment  could  cause  injury  or  death 
(e.g.,  swimming).  Due  to  data  limitations,  we  were 
unable  to  include  categories  4-6  in  our  calculation  of 
risky  drinkers. 


-40- 


misuse  controlled  prescription  drugs,  use 
illicit  drugs'  9  or  engage  in  some 
combination  of  these  forms  of  substance  use 
but  do  not  meet  clinical  diagnostic  criteria 
for  addiction.  Risky  use  can  result  in 
devastating  and  costly  health  and  social 
consequences,  including  the  disease  of 
addiction.  Risky  users  are  targets  for  public 
health  efforts  aimed  at  reducing  risky  use 
and  of  medical  and  other  health  professional 
efforts  to  prevent  risky  use  from  progressing 
to  the  disease  of  addiction. 


To  determine  the  scope  of  risky  substance  use 
and  addiction  in  the  United  States,  CASA 
Columbia  examined  national  prevalence  data1 
for  the  total  U.S.  non- institutionalized 
population  ages  12  and  older.  For  these 
analyses,  we  examined  current  (past  30  day)  use 
of  tobacco,  alcohol  and  other  drugs  and  the  rate 
of  addiction  involving  these  substances.  Our 
definition  of  addiction  in  this  report  is  consistent 
with  the  parameters  used  in  the  national  survey 
upon  which  our  analyses  are  based-the  National 
Survey  on  Drug  Use  and  Health  (NSDUH)— 
which  categorizes  respondents  on  the  basis  of 
diagnostic  criteria  used  in  the  Nicotine 
Dependence  Syndrome  Scale  (NDSS)  for 
nicotine  dependence  and  in  the  DSM-IV  for 


alcohol  and  other  drug  abuse  or  dependence. 
We  also  examined  variations  in  the  rates  of  risky 
use  and  addiction  by  age,  gender  and  race/ 
ethnicity.  Because  of  the  heightened 
vulnerability  to  addictive  substances  while  the 
brain  is  still  developing,5  10  we  present  data  for 
the  following  age  groups:  12-  to  17-year  olds; 
18-  to  25-year  olds;  and  those  ages  26  and  older. 
While  the  NSDUH  was  used  for  these  analyses 
to  present  consistent  data  across  age  groups,  it  is 
important  to  note  that  these  data  appear  to 
underestimate  rates  of  current  substance  use 
among  adolescents  by  at  least  half"  11 

Risky  Substance  Users 


Approximately  one-third  (31.7  percent)  of  the 
U.S.  population  ages  12  and  older  (80.4  million 
people)  currently' f  use  one  or  more  addictive 
substances  in  ways  that  threaten  their  own  health 
and  safety-including  increasing  the  risk  of 
addiction— or  the  health  and  safety  of  others,  but 
do  not  meet  clinical  criteria  for  addiction. 
(Table  3.1)  Nearly  one-third  (30.6  percent)  of 
risky  users  engage  in  risky  use  of  two  or  more 
substances.  Alcohol  is  the  substance  most 
frequently  implicated  in  risky  substance  use, 
followed  by  tobacco.12 


For  data  analysis  purposes,  the  national  survey 
examined  for  this  report  defines  misuse  of  controlled 
prescription  medications  more  generally  as  "taking  a 
controlled  prescription  drug  not  prescribed  for  you  or 
taking  it  in  a  manner  not  prescribed  for  the 
experience  or  feeling  it  causes."  Fhe  misuse  of  over- 
the-counter  medications  also  constitutes  risky  use; 
however,  rates  of  risky  use  in  this  report  do  not 
include  the  misuse  of  these  medications  since  they 
are  not  measured  directly  in  the  national  surveys  that 
were  analyzed  for  this  study. 

'  Substances  controlled  (either  through  prohibited  or 
restricted  use)  through  the  federal  Controlled 
Substances  Act  of  1970  which  created  a  system  for 
classifying  illicit  and  prescription  drugs  according  to 
their  medical  value  and  their  potential  for  misuse.  In 
this  analysis,  illicit  drugs  include  marijuana/hashish, 
cocaine/crack,  heroin,  hallucinogens,  Ecstasy, 
methamphetamine  and  inhalants. 
*  Fhe  most  recent  data  available  (2010)  from  the 
Substance  Abuse  and  Mental  Health  Association's 
(SAMHSA)  National  Survey  on  Drug  Use  and 
Health  (NSDUH). 


s  See  Chapter  II. 

**  Because  the  NSDUH  is  conducted  in  the  home 
where  an  adult  must  be  present,  reported  prevalence 
rates  for  teens  are  significantly  lower  than  reported 
rates  in  school-based  surveys  where  greater 
anonymity  is  assured.  For  example,  the  Youth  Risk 
Behavior  Survey's  (YRBS)  prevalence  estimates  for 
12-  to  17-year  olds  are  2.15  to  2.75  times  as  high  as 
those  presented  in  the  NSDUH. 
ff  In  the  past  30  days. 


-41- 


Table  3.1 

Prevalence  of  Current  Risky  Use*  of 
Addictive  Substances  in 
U.S.  Population,  Ages  12+,  2010 


Percent  of 

Total 
Population 

Number 

(in 
Millions) 

Total  Risky  Use 

31.7 

80.4 

Tobacco  With/Without 
Other  Substances 

18.5 

47.0 

Tobacco  Only 

6.7 

17.0 

AlCOilOl  W  llw  W  ltflOUt 
Winer  oUDSiances 

27.2 

69.0 

Alcohol  Only 

14.3 

36.2 

Illicit  Drugs 
WithAVithout 
Other  Substances 

5.8 

14.6 

Illicit  Drugs  Only 

0.6 

1.6 

Controlled  Prescription 
Drugs  With/Without 
Other  Substances 

2.1 

5.4 

Controlled  Prescription 
Drugs  Only 

0.5 

1.1 

Multiple  Substances 

9.7 

24.6 

Individuals  included  in  the  risky  use  category  used 
the  substance  in  the  past  30  days  but  do  not  meet 
diagnostic  criteria  for  addiction. 
Source:  CASA  Columbia  analysis  of  The  National 
Survey  on  Drug  Use  and  Health  (NSDUH),  2010. 

Young  adults,  ages  18-  to  25-  years  old,  are 
more  likely  to  engage  in  risky  substance  use 
than  any  other  age  group.  (Figure  3. B)  Men  are 
somewhat  likelier  to  be  risky  substance  users 
than  women:  33.9  percent  (41.8  million)  vs. 
29.6  percent  (38.6  million).13 

Whites,  Hispanics  and  blacks  are  likelier  to 
engage  in  risky  substance  use  than  persons  of 
other  races/ethnicities.*  14  (Figure  3. C) 


Figure  3.B 

Current*  Risky  Substance  Use 
Among  Individuals  Ages  12+,  2010 
Percent  (Number  in  Millions) 


31.7 
(80.4  M) 


40.9 
(13.9  M) 


J 


14.3 

(3.5  M) 


r 


32.3 
(63.0  M) 


Total 


12  to  17 


18  to  25 


26+ 


*  In  the  past  30  days. 

Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  201 0. 


Figure  3.C 

Current*  Risky  Substance  Use 
Among  Individuals  Ages  12+  by  Race/Ethnicity, 
2010 

Percent  (Number  in  Millions) 


White 


Black 


Hispanic 


Other 


*  In  the  past  30  days. 

Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  201 0. 


The  proportion  of  the  population  engaging  in 
risky  substance  use  has  remained  stable  over  the 
past  decade;  in  2002,  31.1  percent  (73.1  million) 
were  risky  substance  users,  as  were  31.7  percent 
(80.4  million)  in  20 10. 15 


"Other"  races/ethnicities  include  American 
Indian/ Alaska  Native,  Asian,  Native  Hawaiian/Other 
Pacific  Islander  and  multiracial  non-Hispanic.  These 
races/ethnicities  were  combined  for  purposes  of 
analysis  because  there  are  too  few  respondents  in 
each  category  to  calculate  meaningful  prevalence 

data  for  each  category  separately.  The  "other   

races/ethnicities"  category  is  reported  as  a  group  vary  between  each  racial/ethnic  group  in  this 

despite  the  fact  that  substance  use  prevalence  rates  category. 


-42- 


Risky  Tobacco  Use 

In  2010,  18.5  percent  of  the  U.S.  population 
ages  12  and  older  (47.0  million)  reported  current 
risky  use*  of  a  tobacco  product: 


Risky  tobacco  use  is  slightly  higher  among 
blacks  than  among  whites  and  Hispanics;  risky 
use  in  these  groups  is  higher  than  among  persons 


of  other  races/ethnicities.20  (Figure  3.E) 


•  Cigarettes:  14.0  percent  (35.5 
million); 

•  Cigars:  4.2  percent  (10.6  million); 

•  Smokeless  tobacco  products:  3.0 
percent  (7.7  million);  and 

•  Pipe  tobacco:  0.7  percent  (1.7 
million).1  16 

The  majority  (59.1  percent)  of  risky 
tobacco  users*  also  are  risky  users  of 
alcohol  or  other  drugs.  While  not  having 
addiction  involving  nicotine,  18.2 
percent  of  risky  tobacco  users  have 
addiction  involving  alcohol  and/or  other 
drugs.17 

Among  all  age  groups,  18-  to  25-  year 
olds  have  the  highest  rate  of  risky 
tobacco  use.18  (Figure  3. D) 

Men  are  nearly  twice  as  likely  as  women 
to  be  risky  tobacco  users  (24.1  percent, 
29.7  million  vs.  13.3  percent,  17.3 
million).19 


Figure  3.D 

Current*  Risky  Tobacco  Use 
Among  Individuals  Ages  12+,  2010 
Percent  (Number  in  Millions) 


30.4 
(10.4  M) 


18.5 
(47.0  M) 


0 


9.0 
(2.2  M) 


17.6 
(34.5  M) 


Total 


12  to  17 


18  to  25 


26+ 


*  In  the  past  30  days. 

Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  201 0. 


Figure  3.E 

Current*  Risky  Tobacco  Use 
Among  Individuals  Ages  12+  by  Race/Ethnicity, 
2010 

Percent  (Number  in  Millions) 


18.7 
(31.8  M) 

20.5 
(6.2  M) 

18.2 
(6.7  M) 

13.8 

(2.3  M) 



White 


Black 


Hispanic 


Other 


*  In  the  past  30  days. 

Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  201 0. 


Used  a  tobacco  product  in  the  past  30  days  but  do 
not  meet  criteria  for  addiction  involving  nicotine 
(i.e.,  nicotine  dependence,  as  defined  by  the  NDSS). 
'  These  percentages  represent  the  proportion  of  the 
U.S.  population  ages  12  and  older  reporting  risky  use 
of  each  type  of  tobacco  product.  These  percentages 
do  not  add  up  to  the  total  of  18.5  percent  because  of 
multiple  substance  use.  Nationally  representative 
data  on  the  use  of  water/  hookah  pipes  to  smoke 
tobacco  are  not  available. 
*  Who  do  not  have  addiction  involving  nicotine. 


-43- 


Between  2002  and  2010,  risky  tobacco  use  in  the 
U.S.  population  ages  12  and  older  decreased 
slightly,  from  19.9  percent  (46.8  million)  in 
2002  to  18.5  percent  (47.0  million)  in  2010. 
Among  adolescents  (ages  12  to  17),  the  decrease 
in  risky  tobacco  use  was  more  pronounced,  from 
12.0  percent  in  2002  to  9.0  percent  in  20 10.21 

Risky  Alcohol  Use" 

In  2010,  27.2  percent  of  the  U.S.  population 
ages  12  and  older  (69.0  million)  were  current 
risky  drinkers:22 

•  24.2  percent  were  age  21  and  older  who,  on 
average,  exceeded  the  USDA  guidelines  for 
safe  alcohol  use; 

•  2.9  percent  were  under  age  21  and  drank 
alcohol;  and 

•  0. 1  percent  were  adult  pregnant  women  who 
drank  alcohol. '  23 

Within  this  population  of  risky  drinkers: 

•  69.6  percent1  were  heavy  drinkers- 
consuming  more  than  three  drinks  on  any 
day  or  more  than  seven  drinks  in  any  week 
for  women,  and  more  than  four  drinks  on 


any  day  or  more  than  14  drinks  in  any  week 
for  men;§ 

•  65. 1  percent**  were  current  binge  drinkers- 
consuming  five  or  more  drinks  on  the  same 
occasion  on  at  least  one  day  in  the  past  30 
days;  and 

•  14.7  percent' '  were  current  heavy  binge 
drinkers-binge  drinking  on  at  least  five  days 
in  the  past  30  days.K  24 

More  than  half  (52.6  percent)  of  all  current 
drinkers  are  risky  drinkers.  Nearly  half  (46.4 
percent)  of  risky  drinkers§§  also  are  risky  users 
of  tobacco  or  other  drugs.  While  not  having 
addiction  involving  alcohol,  14.2  percent  of 
risky  drinkers  have  addiction  involving  nicotine 
and/or  other  drugs.25 

As  with  tobacco,  18-  to  25-year  olds  have  the 
highest  rates  of  risky  alcohol  use.26  One  in  10 
adolescents  ages  12  to  17  are  risky  drinkers.*** 27 
(Figure  3.F) 


Based  on  the  USDA  Guidelines  for  safe  alcohol  use 
described  on  page  40.  Excluded  from  the  category  of 
risky  drinkers  are  those  who  meet  diagnostic  criteria 
for  addiction  involving  alcohol  in  the  past  year. 
Because  the  analyses  were  restricted 
to  the  data  available  in  the  NSDUH,  the  component 
of  risky  alcohol  use  that  reflects  the  USDA 
guidelines  of  no  more  than  one  drink  a  day  for 
women  and  two  for  men  was  measured  by  the  item: 
"On  the  days  that  you  drank  during  the  past  30  days, 
how  many  drinks  did  you  usually  have?"  As  such,  it 
represents  the  average  amount  respondents  drink  on 
days  that  they  drink.  If  a  woman  drinks,  on  average, 
more  than  one  drink  a  day  on  days  that  she  drinks  or 
if  a  man  drinks,  on  average,  more  than  two  drinks  a 
day  on  days  that  he  drinks,  she  or  he  would  be 
considered  a  risky  drinker  in  this  analysis. 
'  A  portion  of  this  category  is  included  in  the  adult 
risky  drinker  category  above. 
*  18.9  percent  of  the  population  (ages  12  and  older), 
48.0  million  people. 


§  Due  to  limitations  of  the  NSDUH  data  set,  weekly 
consumption  was  computed  as  an  average  of  monthly 
drinking  divided  by  4.33,  or  52  weeks  / 12  months. 
**  17.7  percent  of  the  population,  44.9  million  people. 
^  4.0  percent  of  the  population,  10.1  million  people. 
**  Rates  of  heavy,  binge,  and  heavy  binge  drinkers 
include  only  risky  alcohol  users  who  do  not  have 
addiction  involving  alcohol. 
§§  Who  do  not  have  addiction  involving  alcohol. 

For  individuals  under  age  2 1 ,  any  alcohol  use  (in 
the  past  30  days)  that  does  not  meet  criteria  for 
addiction  is  considered  risky  drinking. 


-44- 


Figure  3.F 

Current*  Risky  Alcohol  Use 
Among  Individuals  Ages  12+,  2010 
Percent  (Number  in  Millions) 


40.2 
(13.7  M) 


27.2 


1 


) 

27.1 
(52.9  M) 

10.2 
(2.5  M) 

I 

Total 


12  to  17 


1 8  to  25 


26+ 


*  In  the  past  30  days. 

Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  2010. 


Those  ages  1 8  to  25  engage  in  binge  and  heavy 
binge  drinking  at  significantly  higher  rates  than 
those  ages  26  and  older.* 28  (Table  3.2) 


More  men  than  women  engage  in  risky  drinking 
(28.3  percent,  34.9  million  vs.  26.2  percent,  34.1 
million).  This  difference  becomes  more 
pronounced  at  higher  levels  of  drinking:  men 
are  almost  twice  as  likely  as  women  to  be  heavy 
drinkers  (23.8  percent  vs.  14.3  percent)  and 
binge  drinkers  (23.6  percent  vs.  12.1  percent), 
and  three  times  as  likely  to  be  heavy  binge 
drinkers  (6.2  percent  vs.  1.9  percent).29 

Overall,  whites  are  more  likely  to  engage  in 
risky  drinking  compared  to  persons  of  other 
races/ethnicities;  however,  Hispanics  are  slightly 


Other  national  data  indicate  that  while  the 
prevalence  and  intensity  of  binge  drinking  is  highest 
among  individuals  ages  18  to  34,  adults  ages  65  and 
older  who  binge  drink  do  so  more  frequently  than  any 
other  age  group.  Data  regarding  involvement  in  each 
type  of  substance  in  this  table  and  in  subsequent 
tables  demonstrating  demographic  differences  are 
presented  as  any  involvement  with  the  substance 
(with  or  without  involvement  with  other  substances) 
because  presenting  risky  use  for  each  substance  on  its 
own  (without  other  substance  involvement)  results  in 
cell  sizes  that  are  too  small  to  present  reliable  data. 
As  such,  data  on  specific  substances  and  multiple 
substances  shown  in  the  tables  are  not  mutually 
exclusive. 


more  likely  to  engage  in  heavy  and  binge 


drinking.30  (Table  3.3) 


Table  3.2 

Prevalence  of  Current  Heavy,  Binge  and  Heavy 
Binge  Drinking,*  by  Age,  2010 
Percent  (Number  in  Millions) 


Heavy 

Binge 

Heavy 

Drinking 

Drinking 

Binge 

Drinking 

Total  Heavy,  Binge, 

and  Heavy  Binge 

18.9 

17.7 

4.0 

Drinking,  Ages  12+ 

(48.0  M) 

(44.9M) 

(10.1M) 

Age: 

12-  to  17-years  old 

5.2 

5.0 

0.8 

18-  to  25-years  old 

28.8 

28.0 

7.3 

26+  years  old 

18.9 

17.5 

3.8 

Were  risky  users  of  alcohol  in  the  past  30  days  but  do  not 
meet  diagnostic  criteria  for  addiction  involving  alcohol. 
Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  2010.  

Table  3.3 

Prevalence  of  Current  Risky,  Heavy,  Binge  and 
Heavy  Binge  Drinking,*  by  Race/Ethnicity,  2010 
Percent  (Number  in  Millions) 


Total  Risky 
Alcohol  Use 


Heavy  Drinking 


Binge  Drinking 


Heavy  Binge 
Drinking 


White 


28.5 
(48.4M) 


19.7 


18.1 


4.7 


Black       Hispanic  Other 


24.9 
(7.5M) 


16.0 


15.6 


2.2 


27.0 
(9.9M) 


20.7 


20.1 


2.9 


19.2 
(3.2M) 


12.6 


11.9 


1.9 


Were  risky  users  of  alcohol  in  the  past  30  days  but  do  not 
meet  diagnostic  criteria  for  addiction  involving  alcohol. 
Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  2010.  


Between  2002  and  2010,  risky  alcohol  use  in  the 
U.S.  population  ages  12  and  older  increased 
slightly,  from  26.4  percent  (62.0  million)  in 
2002  to  27.2  percent  (69.0  million)  in  20 10.31 
This  increase  was  consistent  across  all  forms  of 
risky  drinking: 

•    Heavy  drinking,  from  18.2  percent  to  18.9 
percent; 


-45- 


•  Binge  drinking,  from  16.9  percent  to  17.7 
percent;  and 

•  Heavy  binge  drinking  from  3.8  percent  to 
4.0  percent.32 

Risky  Illicit  Drug  Use 

In  2010,  5.8  percent  of  the  U.S.  population  ages 
12  and  older  (14.6  million)  reported  current 
risky  use  of  illicit  drugs,*  primarily  marijuana:33 

•  Marijuana/hashish:  5.6  percent  (14.2 
million); 

•  Cocaine/crack:  0.3  percent  (0.8  million); 

•  Hallucinogens:  0.3  percent  (0.8  million); 

•  Ecstasy:  0.2  percent  (0.4  million);  and 

•  Inhalants:  0.2  percent  (0.5  million).*  34 

Nearly  all  risky  illicit  drug  users  (81.6  percent) 
also  are  risky  users  of  tobacco,  alcohol  or 
controlled  prescription  drugs.  While  not  having 
addiction  involving  illicit  drugs,  40.3  percent 
has  addiction  involving  nicotine,  alcohol  and/or 
controlled  prescription  drugs.35 

Risky  use  of  illicit  drugs  is  highest  among  1 8-  to 
25-year  olds;  adolescents  ages  12  to  17  are  more 
likely  to  be  risky  users  of  illicit  drugs  than  adults 
ages  26  and  older.  (Figure  3.G)  Risky 
marijuana  use  follows  the  same  pattern,  with 
13.6  percent  (4.7  million)  of  18-  to  25-year  olds, 
4.9  percent  (1.2  million)  of  12  to  17-year-olds 
and  4.0  percent  of  those  ages  26  and  older  (7.9 
million)  engaging  in  risky  use  of  marijuana/  36 


Used  an  illicit  drug  in  the  past  30  days  but  do  not 
have  addiction  involving  illicit  drugs.  Data  on  the 
risky  use  of  methamphetamine  and  heroin  cannot  be 
reported  separately  due  to  small  sample  size. 
'  These  percentages  do  not  add  up  to  the  total  of  5.8 
percent  because  of  multiple  substance  use. 
*  Data  on  the  risky  use  of  other  types  of  illicit  drugs 
cannot  be  reported  separately  by  age,  gender  or 
race/ethnicity  due  to  small  sample  sizes. 


Men  are  nearly  twice  as  likely  as  women  to  be 
risky  users  of  illicit  drugs  (7.5  percent,  9.3 
million  vs.  4.1  percent,  5.3  million).  Men  also 
are  nearly  twice  as  likely  as  women  to  be  risky 
marijuana  users  (7.1  percent,  8.8  million  vs.  3.8 
percent,  4.9  million).37 

Blacks  and  whites  are  more  likely  to  engage  in 
risky  use  of  illicit  drugs  than  Hispanics  or 
persons  of  other  races/ethnicities.38  (Figure  3.H) 


Figure  3.G 

Current*  Risky  Illicit  Drug  Use 
Among  Individuals  Ages  12+,  2010 
Percent  (Number  in  Millions) 


14.2 
(4.8  M) 


5.8 
(14.6  M) 


5.8 
(1.4  M) 


4.3 
(8.4  M) 


Total 


12  to  17 


18  to  25 


26+ 


*  In  the  past  30  days. 

Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  2010. 


Figure  3.H 

Current*  Risky  Illicit  Drug  Use 
Among  Individuals  Ages  12+  by  Race/Ethnicity, 
2010 

Percent  (Number  in  Millions) 


White 


Black 


Hispanic 


Other 


*  In  the  past  30  days. 

Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  201 0. 


-46- 


With  regard  to  the  risky  use  of  marijuana 
specifically,  blacks  are  more  likely  to  be  risky 
users  (6.3  percent,  1.9  million),  than  whites  (5.7 
percent,  9.8  million),  Hispanics  (4.1  percent,  1.5 
million)  or  persons  of  other  races/ethnicities  (3.3 
percent,  0.6  million).39 

The  rate  of  risky  use  of  illicit  drugs  has 
increased  slightly  between  2002  (5.0  percent, 
11.9  million)  and  2010  (5.8  percent,  14.6 
million)  driven  primarily  by  an  increase  in  the 
rate  of  risky  use  of  marijuana  (4.6  percent,  10.7 
million  in  2002  and  5.6  percent,  14.2  million  in 
20 10). 40 

Risky  Use  of  Controlled  Prescription  Drugs 

In  2010,  2.1  percent  of  the  U.S.  population  ages 
12  and  older  (5.4  million)  reported  risky  use  of 
controlled1  prescription  drugs,  with  opioids 
(pain  relievers)  the  most  frequently  misused:41 

•  Opioids:  1.6  percent  (3.9  million); 

•  Tranquilizers:  0.6  percent  (1.5  million);  and 

•  Stimulants:  0.3  percent  (0.7  million). i  42 

Of  those  who  are  risky  userssS  of  controlled 
prescription  drugs,  65.8  percent  (3.6  million) 
also  are  risky  users  of  tobacco,  alcohol  or  illicit 
drugs.  While  not  having  addiction  involving 
controlled  prescription  drugs,  43.6  percent  of 
risky  users  of  these  drugs  have  addiction 
involving  nicotine,  alcohol  and/or  an  illicit 
drug.43 


Risky  use  of  controlled  prescription  drugs  is 
highest  among  18-  to  25-year  olds;  more  12-  to 
17-year  olds  report  risky  use  of  these  drugs  than 


those  ages  26  and  older.44  (Figure  3.1) 


Figure  3.1 

Current*  Risky  Use  of 
Controlled  Prescription  Drugs 
Among  Individuals  Ages  12+,  2010 
Percent  (Number  in  Millions) 


4.3 
(1.5  M) 


2.1 
(5.4  M) 


2.3 
(0.6  M 


1.7 
(3.4  M) 


Total 


12to  17 


18  to  25 


26+ 


*  In  the  past  30  days. 

Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  201 0. 


This  pattern  is  the  same  for  the  risky  use  of 
opioids  specifically:  2.0  percent  of  12-  to  17- 
year  olds,  3.2  percent  of  18-  to  25-year  olds  and 
1.2  percent  of  individuals  ages  26  and  older  are 
risky  users  of  opioids.**45 

Men  are  slightly  likelier  to  be  risky  users  of 
controlled  prescription  drugs  (2.3  percent,  2.8 
million)  than  women  (2.0  percent,  2.6  million). 
With  regard  to  opioids,  men  also  are  more  likely 
to  be  risky  users  (1.8  percent,  2.2  million)  than 
women  (1.3  percent,  1.7  million).46 


Misused  a  controlled  prescription  drug  in  the  past 
30  days  but  do  not  have  addiction  involving 
prescription  drugs. 

'  Controlled  by  the  U.S.  Drug  Enforcement 
Administration  because  of  their  potential  for  misuse. 
*  Data  on  the  risky  use  of  sedatives  cannot  be 
reported  separately  due  to  small  sample  size.  These 
percentages  do  not  add  up  to  the  total  of  2. 1  percent 
because  of  multiple  substance  use. 
§  Who  do  not  have  addiction  involving  prescription 
drugs. 


Data  on  the  risky  use  of  other  classes  of  controlled 
prescription  drugs  cannot  be  reported  separately  by 
age,  gender  or  race/ethnicity  due  to  small  sample 
size. 


-47- 


Whites  are  more  likely  to  be  risky  users  of 
controlled  prescription  drugs  than  persons  of 
other  races/ethnicities.47  (Figure  3. J) 


Figure  3. J 

Current*  Risky  Use  of 
Controlled  Prescription  Drugs 
Among  Individuals  Ages  12+  by  Race/Ethnicity, 
2010 

Percent  (Number  in  Millions) 


2.3 
(3.9  M) 


1.7 
(0.5  M) 


2.1 
(0.8  M) 


_□ 


1.3 
(0.2  M) 


White 


Black 


Hispanic 


Other 


*  In  the  past  30  days. 

Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  201 0. 


Addictioiv 

In  2010,  a  total  of  15.9  percent  of  the  U.S. 
population  ages  12  and  older  (40.3  million 
people)  met  clinical  diagnostic  criteria  for 
addiction.1 50 

Addiction  involving  nicotine  and  alcohol  are  the 
most  prevalent  manifestations  of  addiction, 
followed  by  addiction  involving  illicit  drugs  and 
controlled  prescription  drugs.51  (Table  3.4) 


However,  with  regard  to  the  specific  case  of 
opioids,  Hispanics  are  slightly  likelier  than 
whites  (1.7  percent,  0.6  million  vs.  1.6  percent, 

2.8  million)*  to  misuse  opioids.48 

The  rate  of  risky  use  of  controlled  prescription 
drugs  has  remained  relatively  stable  between 
2002  (2.2  percent,  5.2  million)  and  2010  (2.1 
percent,  5.4  million);  the  rate  of  risky  use  of 
opioids  also  has  remained  stable  between  2002 
(1.5  percent,  3.6  million)  and  2010  (1.6  percent, 

3.9  million).49 


Data  on  risky  opioid  use  among  blacks  (1.3  percent) 
and  persons  of  other  races/ethnicities  (1.0  percent) 
cannot  be  reported  as  statistically  significant  due  to 
small  sample  sizes. 


'  The  term  "addiction"  is  used  synonymously  in  this 
report  with  the  NDSS  criteria  for  past  30  day  nicotine 
dependence,  and  the  DSM-IV  clinical  diagnostic 
criteria  for  past  year  alcohol  and/or  other  drug  abuse 
and  dependence  (excluding  nicotine)  in  accordance 
with  the  Diagnostic  and  Statistical  Manual  of  Mental 
Disorders  (DSM-IV).  (The  DSM  refers  to  substance 
abuse  and  substance  dependence  collectively  as 
substance  use  disorders.  The  diagnostic  criteria  for 
nicotine  dependence  in  the  NDSS  parallel  those  of 
the  DSM-IV).  These  are  the  criteria  used  by  the 
NSDUH  to  classify  respondents  as  having  a 
substance  use  disorder.  This  definition  is  consistent 
with  the  current  move  to  combine  abuse  and 
dependence  into  an  overarching  diagnosis  of 
addiction  in  the  upcoming  DSM-V.  Available  data 
allow  us  to  include  in  our  prevalence  estimates  only 
those  who  meet  behavioral  criteria  in  accordance 
with  the  current  diagnostic  standards,  meaning  that 
their  disease  is  not  effectively  managed  or  has  not 
reached  the  point  of  behavioral  symptoms. 
Individuals  who  have  the  disease  of  addiction  but  do 
not  meet  diagnostic  criteria  for  past  month  (nicotine) 
or  past  year  (alcohol  or  other  drug)  addiction  are  not 
included. 

*  This  estimate  excludes  the  institutionalized 
population,  for  which  rates  of  addiction  are  higher. 


-48- 


Table  3.4 
Prevalence  of  Addiction  in 
U.S.  Population,  Ages  12+,  2010 


Percent  oi 

XT  1_ 

Number 

Total 

s 

Population 

Millions) 

Total  AHHirtinn* 

Nicotine  With/ Without 

9.0 

22.9 

Other  Substances 

Nicotine  Only 

7.1 

18.0 

Alcohol  With/Without 

7.1 

18.0 

Other  Substances 

Alcohol  Only 

5.0 

12.6 

Illicit  Drugs 

With/Without  Other 

2.2 

5.6 

Substances 

Illicit  Drugs  Only 

0.8 

2.1 

Controlled  Prescription 

Drugs  With/Without 

0.9 

2.4 

Other  Substances 

Controlled  Prescription 
Drugs  Only 

0.2 

0.6 

Multiple  Substances 

2.7 

7.0 

Based  on  past  30-day  nicotine  dependence,  as  defined 
in  the  NDSS,  and  past-year  alcohol  and/or  other  drug 
abuse  or  dependence,  as  defined  in  the  DSM-IV. 
Source:  CASA  Columbia  analysis  of  The  National 
Survey  on  Drug  Use  and  Health  (NSDUH),  2010. 


Those  ages  1 8  to  25  have  the  highest  rate  of 
addiction,  including  the  highest  rates  involving 
each  type  of  substance,  than  any  other  age 


group.53  (Figure  3.K;  Table  3.5T) 


Figure  3.K 

Addiction  Among  Individuals  Ages  12+,  2010 
Percent  (Number  in  Millions) 


26.4 

(9.0  m; 


15.9 
(40.3  M) 


D 


8.0 
(2.0  M) 


15.0 
(29.3  M) 


Total 


12  to  17 


18  to  25 


26+ 


Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  201 0. 


Among  those  with  addiction,  55.7  percent  are 
risky  users  of  one  or  more  other  substances  and 
17.3  percent  have  addiction  involving  multiple 
substances,  including: 

•    21.3  percent  of  those  with  addiction 
involving  nicotine; 


•    30. 1  percent  of  those  with  addiction 
involving  alcohol; 


•  75.2  percent  of  those  with  addiction 
involving  controlled  prescription  drugs;  and 

•  62. 1  percent  of  those  with  addiction 
involving  illicit  drugs.52 


Met  diagnostic  criteria  for  two  or  more  of  the 
following:  past  30-day  nicotine  dependence  and/or 
past  year  abuse/dependence  involving  alcohol,  illicit 
drugs  and/or  controlled  prescription  drugs. 


1  Data  regarding  addiction  involving  each  type  of 
substance  in  this  table  and  in  subsequent  tables 
demonstrating  demographic  differences  are  presented 
as  addiction  involving  the  substance,  with  or  without 
addiction  involving  other  substances,  because 
presenting  addiction  related  to  each  substance  on  its 
own  (without  other  substance  addiction)  results  in 
cell  sizes  that  are  too  small  to  present  reliable  data. 
As  such,  data  on  specific  substances  and  multiple 
substances  shown  in  the  tables  are  not  mutually 
exclusive. 


-49- 


Table  3.5 

Prevalence  of  Addiction,  by  Age  Group,  2010 
Percent  (Number  in  Millions) 


12- to 

18- to 

26+ 

17-  years 
old 

25-  years 
old 

years 
old 

Total  Addiction, 

8.0 

26.4 

15.0 

Ages  12+ 

(2.0M) 

(9.0M) 

(29.3M) 

Nicotine  With/Without 

Other  Substance 

Addiction 

1.8 

10.4 

9.7 

Alcohol  With/Without 

Other  Substance 

Addiction 

4.6 

15.8 

5.9 

Illicit  Drugs 

With/Without  Other 

Substance  Addiction 

4.1 

6.5 

1.2 

Controlled  Prescription 

Drugs  With/Without 

Other  Substance 

Addiction** 

(1.2) 

(2.2) 

(0.7) 

Multiple  Substances 

2.7 

6.7 

2.1 

Based  on  past  30-day  nicotine  dependence,  as  defined  in 
the  NDSS,  and  past-year  alcohol  and/or  other  drug  abuse 
or  dependence,  as  defined  in  the  DSM-IV. 

The  rate  of  addiction  involving  controlled  prescription 
drugs  is  too  low  to  assure  statistical  reliability  of  data  by 
age. 

Source:  CASA  Columbia  analysis  of  The  National  Survey 
on  Drug  Use  and  Health  (NSDUH),  2010.  

It  is  important  to  note  that  8.0  percent  of 
adolescents  ages  12  to  17  have  addiction.54  The 
percent  of  adults  who  meet  clinical  criteria  for 
addiction  declines  with  age.*  The  explanation 
for  this  is  not  well  understood  and  reliable 
national  data  are  not  available  on  the  proportion 
of  those  with  addiction  for  whom  the  disease  is 
chronic.  It  may  be  that  some  young  people 
receive  treatment  or  otherwise  successfully 
manage  the  disease  to  the  point  where  they  no 
longer  meet  diagnostic  criteria  for  addiction  as 
they  get  older,  while  for  some  other  young 
people  the  disease  may  be  fatal. 


Men  are  more  likely  to  have  addiction  than 
women  (19.1  percent,  23.6  million  vs.  12.8 
percent,  16.6  million).  While  rates  of  addiction 
involving  nicotine  and  controlled  prescription 
drugs  are  similar  for  both  genders,  rates  of 
addiction  involving  all  other  substances  are 
twice  as  high  among  men  as  women.55 
(Table  3.6) 

Table  3.6 

Prevalence  of  Addiction,"  by  Gender,  2010 
Percent  (Number  in  Millions) 


Total  Addiction, 
Ages  12+  


Nicotine  With/Without  Other 
Substance  Addiction 


Alcohol  With/Without  Other 
Substance  Addiction 


Illicit  Drugs  With/Without 
Other  Substance  Addiction 


Controlled  Prescription  Drugs 
With/Without  Other 
Substance  Addiction 


Multiple  Substances 


Males  Females 


19.1 

(23.6M) 


9.9 


9.5 


2.9 


(1.1) 


3.5 


12.8 
(16.6M) 


8.2 


4.8 


1.6 


(0.8) 


2.0 


Based  on  past  30-day  nicotine  dependence,  as 
defined  in  the  NDSS,  and  past-year  alcohol  and/or 
other  drug  abuse  or  dependence,  as  defined  in  the 
DSM-IV. 

**  The  rate  of  addiction  involving  controlled 
prescription  drugs  is  too  low  to  assure  statistical 
reliability  of  data  by  gender. 

Source:  CASA  Columbia  analysis  of  The  National 
Survey  on  Drug  Use  and  Health  (NSDUH),  2010. 


23.7  percent  (8.6  million)  of  adults  ages  26-34; 
16.8  percent  (10.5  million)  of  adults  ages  35-49; 
13.8  percent  (7.9  million)  of  adults  ages  50-64;  and 
5.8  percent  (2.3  million)  of  adults  ages  65  and  older. 


-50- 


Whites  are  more  likely  to  have  addiction  than 
individuals  of  other  races/ethnicities.  Rates  of 
addiction  involving  nicotine  are  highest  among 
whites,  while  rates  of  addiction  involving 
alcohol  are  highest  among  whites  and  Hispanics. 
Rates  of  addiction  involving  illicit  drugs  are 
highest  among  blacks.56  (Table  3.7) 

Between  2002  and  20 1 0,  the  rate  of  addiction 
declined  from  17.6  percent  (41.4  million)  to  15.9 
percent  (40.3  million),  driven  primarily  by  the 
decline  in  rates  of  addiction  involving  nicotine 
(10.5  percent  in  2002  to  9.0  percent  in  2010).57 

Special  Populations 

Certain  populations-such  as  pregnant  women, 
the  young  and  the  elderly-are  more  vulnerable 
to  the  damaging  and  addictive  effects  of 
tobacco,  alcohol  and  other  drugs.  Among 
individuals  with  co-occurring  disorders, 
members  of  the  military  exposed  to  combat  and 
persons  involved  in  the  justice  system,  the 
likelihood  of  risky  use  and  addiction  is 
significantly  higher  than  in  the  general 
population. 

Pregnant  Women 

In  2010,  16.2  percent  of  pregnant  women  were 
risky  users  of  tobacco,  alcohol  or  other  drugs 
and  14.7  percent  of  pregnant  women  met  clinical 
criteria  for  addiction. '  Although  pregnant 
women  are  less  likely  to  engage  in  risky 
substance  use  or  have  addiction  than  non- 
pregnant women,58  any  substance  use  by 
pregnant  women  is  concerning  because  of  the 
risk  of  pregnancy  complications,  adverse  health 
consequences  for  the  fetus  and  health  and 
behavioral  consequences  for  children  prenatally 
exposed  to  addictive  substances.59 

Adolescents  and  Young  Adults 

Use  of  tobacco,  alcohol  and  other  drugs  while 
the  brain  is  still  developing  increases  the  risk  of 
addiction.  Because  the  brain  continues  to 


Compared  to  34.2  percent  of  non-pregnant  women. 
Compared  to  16.2  percent  of  non-pregnant  women. 


Table  3.7 

Prevalence  of  Addiction,*  by  Race/Ethnicity,  2010 
Percent  (Number  in  Millions) 


White 

Black 

Hispanic 

Other 

Total  Addiction, 
Ages  12+ 

17.6 
(29.9M) 

13.4 
(4.0M) 

12.9 
(4.7M) 

9.9 
(1.6M) 

Nicotine  With/ 
Without  Other 
Substance  Addiction 

10.9 

6.9 

4.2 

4.9 

Alcohol  With/  Without 
Other  Substance 
Addiction 

7.4 

5.8 

7.6 

5.0 

Illicit  Drugs  With/ 
Without  Other 
Substance  Addiction 

1.9 

3.5 

2.9 

1.6 

Controlled  Prescription 
Drugs  With/Without 
Other  Substance 
Addiction 

(1.0) 

(0.6) 

(1.0) 

(0.7) 

Multiple  Substances 

2.9 

2.9 

2.4 

2.0 

Based  on  past  30-day  nicotine  dependence,  as  defined  in  the 
NDSS,  and  past-year  alcohol  and/or  other  drug  abuse  or  dependence, 
as  defined  in  the  DSM-IV. 


The  rate  of  addiction  involving  controlled  prescription  drugs  is  too 
low  to  assure  statistical  reliability  of  data  by  race/ethnicity. 
Source:  CASA  Columbia  analysis  of  The  National  Survey  on  Drug 
Use  and  Health  (NSDUH),  2010.  


develop  into  the  mid-20s,  the  use  of  tobacco, 
alcohol,  controlled  prescription  drugs  and  illicit 
drugs  among  12-  to  25-year  olds  is  a  significant 
public  health  concern.60  Despite  this,  risky 
substance  use  is  high  in  this  age  group: 

•  About  half  (50.6  percent,  29.6  million)  of 
12-  to  25-year  olds  have  used  a  tobacco 
product1  in  their  lifetime; 

•  Two-thirds  (64.9  percent,  37.9  million)  of 
12-  to  25-year  olds  have  used  alcohol  in 
their  lifetime; 

•  Four  in  10  (40.6  percent,  23.7  million)  12- 
to  25-year  olds  have  used  an  illicit  drug  in 
their  lifetime;  and 

•  Approximately  one-fifth  (21.0  percent,  12.3 
million)  of  12-  to  25 -year  olds  have  misused 


1  Includes  cigarettes,  cigars,  pipes  and  smokeless 
tobacco. 


-51- 


a  controlled  prescription  drug  in  their 
lifetime.61 

Older  Adults 

The  body's  tolerance  to  addictive  substances 
declines  with  age,62  while  the  quantity  and 
frequency  of  prescription  drug  use  typically 
increases.63  These  factors  contribute  to  an 
increased  chance  of  risky  substance  use  and 
addiction.  Also,  as  the  "Boomer"  generation 
ages,  seniors  are  reporting  increasingly  higher 
rates  of  substance  use  and  addiction,  due  to  the 
higher  rates  of  substance  use  in  this  age  cohort 
compared  with  prior  generations.64  Currently, 
25.2  percent  of  the  population  ages  50  and  older 
engages  in  risky  substance  use  and  10.6  percent 
has  addiction.* 65 

Co-occurring  Disorders 

Addiction  frequently  co-occurs  with  other  health 
conditions.66  CASA  Columbia's  analysis  of 
national  data  indicates  that  in  the  past  year,  57.5 
percent  of  non-institutionalized  individuals  ages 
18  and  older f  with  addiction  also  have  another 
health  condition: 

•  31.9  percent  have  been  told  by  a  doctor  that 
they  have  a  medical  condition4  (not 
including  mental  health  disorders);  and 

•  39.4  percent  meet  clinical  criteria  for  a 
mental  health  disorder. §  67  (Figure  3.L) 


The  sample  size  is  too  low  to  provide  any  further 
statistically  reliable  data  on  older  adults  ages  65  and 
older. 

'  Data  on  mental  health  disorders  among  12-  to  17- 
year  olds  are  not  available  in  the  NSDUH. 
*  In  the  past  year.  Includes  asthma,  bronchitis, 
cirrhosis  of  the  liver,  diabetes,  heart  disease, 
hepatitis,  high  blood  pressure,  HIV/AIDs,  lung 
cancer,  pancreatitis,  pneumonia,  STDs,  sinusitis, 
sleep  apnea,  stroke,  tinnitus,  tuberculosis  and  ulcer. 
§  Includes  those  with  a  current  or  past  year  mental, 
behavioral  or  emotional  disorder  (e.g.,  depression  and 
anxiety;  excluding  developmental  disorders  and 
addiction)  that  meets  DSM-IV  criteria,  or  those  with 
a  major  depressive  episode  in  the  past  year. 


Figure  3.L 

Rates  of  Mental  Health  Disorders  Among 
Individuals  Ages  18+  with  Addiction  Involving 
Specific  Substances,  2010 
Percent  (Number  in  Millions) 


71.2 
(1.5  M) 


39.4 
(15.1  M) 


57.2 
(2.6  M) 


44.5 
(7.5  M) 


37.0 
(8.3  M) 


Total 


Controlled 
Prescription 
Drugs 


llicit  Drugs  Alcohol 


Nicotine 


Source:  CASA  Columbia  analysis  of  The  National  Survey  on 
Drug  Use  and  Health  (NSDUH),  201 0. 


People  with  mental  health  disorders  also  are 
more  likely  to  be  risky  substance  users  and  to 
have  addiction  than  those  without  a  mental 
health  disorder.  Among  those  ages  1 8  and  older 
who  have  a  mental  health  disorder,  30.6 
percent  are  risky  substance  users  and  31.4 
percent  have  addiction.68 

In  total,  6.6  percent  of  the  non-institutionalized 
U.S.  population  ages  18  and  older  (15.1  million) 
meet  clinical  criteria  for  both  addiction  and  a 
mental  health  disorder. ' '  69  Those  with  co- 
occurring  addiction  and  mental  health  disorders 
also  are  likelier  to  have  other  co-occurring 
chronic  illnesses  such  as  hypertension,  asthma 
and  arthritis. 


70 


The  rates  of  co-occurring  mental  health 
disorders  appear  to  be  even  higher  among  people 
seeking  treatment  for  addiction.  One  large-scale 
study  of  adolescents  and  adults  in  addiction 
treatment  found  that  two-thirds  of  the  patients 
had  co-occurring  mental  health  disorders  in  the 
year  prior  to  treatment  admission,  with  18-  to 
25 -year  olds  most  likely  to  have  co-occurring 


20.9  percent  of  adults  (18  and  older)  in  the  U.S. 
population  meet  clinical  criteria  for  a  mental  health 
disorder. 

11  These  rates  are  higher  among  institutionalized 
persons;  for  example,  CASA  Columbia's  2010  study, 
Behind  Bars  Update:  Substance  Abuse  and  America's 
Prison  Population,  found  that  24.4  percent  of  prison 
and  jail  inmates  have  both  addiction  and  a  co- 
occurring  mental  health  disorder. 


-52- 


disorders.  Attention  deficit/hyperactivity 
disorder  and  conduct  disorder  are  the  most 
common  co-occurring  mental  health  disorders  in 
young  patients  being  treated  for  addiction,  and 
anxiety  and  depression  are  the  most  common  co- 
occurring  mental  health  disorders  in  older 
patients;  trauma-related  disorders  are  common 
across  age  groups.71 

The  link  between  mental  illness  and  smoking  is 
particularly  striking;72  individuals  age  1 8  and 
older  with  a  mental  illness  involving  serious 
functional  impairment'  are  nearly  twice  as  likely 
as  those  without  such  illnesses  to  have  smoked 
cigarettes  in  the  past  year  (49.8  percent  vs.  27.4 
percent).73  Up  to  60  percent  of  those  with 
depression,  up  to  70  percent  of  those  with 
bipolar  disorder  and  up  to  88  percent  of  those 
with  schizophrenia  either  are  current  or  former 
smokers.1 74  Those  with  clinical  anxiety5  are 
approximately  twice  as  likely  to  be  current 
smokers  (39.2  percent  vs.  22.2  percent),  have 
smoked  twice  as  many  cigarettes  in  the  past 
month  (139.5  cigarettes  vs.  63.4  cigarettes)  and 
are  more  than  twice  as  likely  to  have  addiction 
involving  nicotine  (21.2  percent  vs.  8.4  percent) 
as  smokers  without  anxiety.     Slightly  more 
than  one-quarter  of  the  population  (26.9  percent) 
has  addiction,  a  mental  health  disorder  or  a 
serious  mental  illness,' '  yet  this  group  smokes 
72.9  percent  of  all  cigarettes.75 


Ages  17  and  younger. 

'  National  data  from  2010.  A  diagnosable  mental, 
behavioral  or  emotional  disorder  (excluding 
developmental  disorders  and  addiction  involving 
alcohol  or  drugs  other  than  nicotine)  of  sufficient 
duration  to  meet  diagnostic  criteria  specified  in  the 
DSM-IV  that  has  resulted  in  serious  functional 
impairment,  substantially  interfering  with  or  limiting 
one  or  more  major  life  activities.  Comparable  data 
are  not  available  for  12-  to  17-year  olds. 
*  These  data  are  from  a  review  of  studies  of  clinical 
and  population-based  samples. 
§  Ages  12  and  older. 

Among  smokers,  those  with  anxiety  smoked  an 
average  of  355.5  cigarettes  in  the  past  month 
compared  to  286.2  cigarettes  among  smokers  without 
anxiety. 

' r  A  mental,  behavioral  or  emotional  disorder  that  has 
resulted  in  serious  functional  impairment  which 
substantially  interferes  with  or  limits  one  or  more 
major  life  activities. 


Members  of  the  Military  Exposed  to 
Combat 

Exposure  to  combat  increases  the  risk  of 
addiction  and  co-occurring  mental  health 
problems  such  as  post-traumatic  stress  disorder 
(PTSD),  anxiety  and  depression.  Addiction 
involving  alcohol  is  one  of  the  most  commonly- 
reported  disorders  among  Vietnam  War 
veterans,76  and  co-occurring  addiction  and 
mental  health  disorders  are  most  prevalent 
among  veterans  of  the  Vietnam  era.77  Military 
personnel  and  veterans  of  the  more  recent 
conflicts  in  Afghanistan  and  Iraq  also  are  at 
increased  risk  of  risky  use  and  addiction  as  well 
as  co-occurring  mental  health  disorders.78 

A  study  of  smoking  among  individuals  who 
were  deployed  or  not  deployed  to  Iraq  and 
Afghanistan  found  that  those  who  were 
deployed  were  more  likely  than  those  who  were 
not  deployed  to  initiate  smoking  if  they  never 
smoked  before  (2.3  percent  vs.  1.3  percent),  to 
resume  smoking  if  they  had  smoked  in  the  past 
(39.4  percent  vs.  28.7  percent)  and  to  have  a 
greater  increase  in  their  smoking  rate  if  they 
were  smokers  (57  percent  vs.  44  percent).  The 
same  study  found  that  those  who  were  deployed 
and  reported  combat  exposure  were  1.6  times 
more  likely  to  initiate  smoking  (among  never- 
smokers)  and  1.3  times  more  likely  to  resume 
smoking  (among  past  smokers)  compared  to 
those  who  were  not  exposed  to  combat.  The 
likelihood  of  resumption  of  smoking  post- 
deployment  was  associated  with  length  of 
deployment.;t  79 

One  study  using  data  from  2005  found  that  40 
percent  of  veterans  from  military  operations  in 
Iraq  and  Afghanistan  who  sought  Veterans 
Administration  (VA)  health  care  screened 
positive  for  risky  alcohol  use  and  22  percent 
screened  positive  for  addiction  involving 


11  More  than  nine  months  and  deploying  multiple 
times. 


-53- 


alcohol.      Another  study  found  that  the 
prevalence  of  risky  alcohol  use*  was  higher  after 
deployment  to  Iraq  or  Afghanistan  compared  to 
pre-deployment.81  A  study  of  soldiers  who  were 
interviewed  three  to  four  months  after  returning 
from  deployment  to  Iraq  found  that  25  percent 
engaged  in  risky  alcohol  use.§  Soldiers  who  had 
higher  rates  of  exposure  to  threats  of  injury  or 
death  were  more  likely  to  engage  in  risky 
alcohol  use.82  A  study  of  reserve/National 
Guard  and  active  duty  personnel  found  that 
reserve/National  Guard  personnel  who  were 
deployed  with  combat  exposure  were  1.6  times 
more  likely  than  those  deployed  without  combat 
exposure  to  experience  new-onset  heavy  weekly 
drinking   (8.8  percent  vs.  5.6  percent)  and  1.5 
times  more  likely  to  report  new-onset  binge 
drinking' '  (25.6  percent  vs.  19.3  percent);  active 
duty  personnel  who  were  deployed  to  Iraq  or 
Afghanistan  and  reported  combat  exposure  were 
1.3  times  more  likely  than  those  who  were 
deployed  without  combat  exposure  to  report 
new-onset  binge  drinking  (26.6  percent  vs.  22.0 
percent).83  A  study  of  National  Guard  Brigade 
Combat  Team  soldiers  deployed  to  Iraq  from 
March  2006  to  July  2007  found  that  13  percent 


Based  on  scores  on  a  version  of  the  AUDIT 
instrument  (see  Appendix  H).  Risky  drinking  was 
defined  as  an  AUDIT-C  score  of  three  or  higher  for 
women  and  four  or  higher  for  men.  Addiction  was 
defined  as  an  AUDIT-C  score  of  four  or  higher  for 
women  and  six  or  higher  for  men. 
1  Of  four  U.S.  combat  infantry  units  (three  Army 
units  and  one  Marine  Corps  unit). 
*  Measured  with  a  two-question  instrument  asking, 
"In  the  last  year,  have  you  ever  drunk  or  used  more 
drugs  than  you  meant  to?"  and  "Have  you  felt  you 
wanted  or  needed  to  cut  down  on  your  drinking  or 
drug  use  in  the  last  year?" 

§  Answering  yes  either  to:  "In  the  past  four  weeks, 
have  you  felt  you  wanted  or  needed  to  cut  down  on 
your  drinking?"  or  "In  the  past  four  weeks,  have  you 
used  alcohol  more  than  you  meant  to?" 

Men  who  consumed  more  than  14  drinks  per  week 
and  women  who  consumed  more  than  seven  drinks 
per  week. 

n  Those  who  reported  drinking  five  or  more  drinks 
(for  men)  or  four  or  more  drinks  (for  women)  on  at 
least  one  day  of  the  week  or  those  who  reported 
"drinking  five  or  more  alcoholic  beverages"  on  at 
least  one  day  or  occasion  during  the  past  year. 


met  criteria  for  addiction  involving  alcohol 
when  they  returned  from  deployment.*1 84 

The  risky  use  of  prescription  drugs  also  is 
common  among  active  duty  personnel.  One 
study  found  that  in  2008,  9.9  percent  of  service 
members  misused  prescription  drugs§§  (14.5 
percent  of  Army,  9.1  percent  of  Navy,  10.2 
percent  of  Marine  Corps,  7.5  percent  of  Air 
Force  and  8.0  percent  of  Coast  Guard  service 
members),85  a  rate  far  higher  than  the  2.1  percent 
who  have  misused  controlled  prescription  drugs 
in  the  general  population.86 

Soldiers  exposed  to  combat  who  experience  a 
traumatic  brain  injury  (TBI)  are  at  particularly 
high  risk  for  the  risky  use  of  alcohol  or  other 
drugs  and  for  addiction.  One  study  of  service 
members  who  were  discharged  from  military 
service  found  that  those  with  mild  TBI  were  2.6 
times  more  likely  and  those  with  moderate  TBI 
were  5.4  times  more  likely  to  be  discharged  for 
addiction  involving  alcohol  or  for  drug  use 
compared  to  the  total  discharge  population.87 
Another  study  of  service  members  with  blast- 
induced  mild-to-moderate  injuries  between  2004 
and  2007  found  that  more  than  six  percent  of 
service  members  with  a  mild  TBI  had  post- 
deployment  addiction  involving  alcohol.88 

Post-traumatic  stress  disorder  (PTSD)  also  is 
prevalent  in  the  military  population  and  co- 
occurs  at  high  rates  with  addiction.  One  study 
of  Iraq  and  Afghanistan  veterans  who  were  first- 
time  users  of  VA  health  care,  found  that  among 
those  who  met  criteria  for  addiction  involving 
alcohol  and/or  other  drugs,  63  to  76  percent  also 
met  diagnostic  criteria  for  PTSD.89 


**  Sixty-two  percent  of  these  soldiers  met  criteria 
prior  to  deployment  while  38  percent  had  a  new 
onset— that  is,  they  met  criteria  post-deployment. 
§§  In  the  past  30  days,  misused  prescription-type 
amphetamines/ stimulants  (including 
methamphetamine),  tranquilizers/muscle  relaxers, 
barbiturates/sedatives  or  opioids/pain  relievers. 


-54- 


Involvement  in  the  Justice  System 

Adolescents  (ages  12  to  17)  who  have  a  lifetime 
history  of  arrest  are  three  times  more  likely  to 
engage  in  risky  substance  use  or  have  addiction 
compared  with  adolescents  who  have  no  arrest 
record  (60. 1  percent  vs.  19.8  percent).90  They 
are: 


•  Twice  as  likely  to  be  risky  substance  users 
(24.5  percent  vs.  13.7  percent);  and 

•  Five-and-a-half  times  as  likely  to  have 
addiction  (35.6  percent  vs.  6.2  percent).91 

Previous  research  by  CASA  Columbia  has  found 
that  78.4  percent  of  10-  to  17-year  olds  who  are 
in  juvenile  justice  systems  are  substance- 
involved;*  92  52.4  percent  of  juvenile  or  youthful 
offenders  incarcerated  in  state  prisons  and  local 
jails  meet  clinical  criteria  for  addiction  involving 
alcohol  or  other  drugs.93 

Those  ages  1 8  and  older  who  have  ever  been 
arrested  are  almost  twice  as  likely  to  engage  in 
risky  substance  use  or  have  addiction  compared 
to  those  with  no  arrest  record  (74.5  percent  vs. 
45.0  percent).  More  specifically,  while  they  are 
slightly  more  likely  to  be  risky  substance  users 
without  having  addiction  (38.1  percent  vs.  32.5 
percent),  they  are  three  times  as  likely  to  meet 
diagnostic  criteria  for  addiction  (36.4  percent  vs. 
12.5  percent).94 


They  were  under  the  influence  of  alcohol  or  other 
drugs  while  committing  their  crime,  test  positive  for 
drugs,  are  arrested  for  committing  an  alcohol  or  other 
drug  offense,  admit  having  substance-related 
problems  or  addiction  or  share  some  combination  of 
these  characteristics. 


Previous  research  by  CASA  Columbia  found 
that  the  majority  (84.8  percent)  of  all  inmates  are 
substance  involved;1  64.5  percent  of  the  inmate 
population  (nearly  1.5  million  people)  has 
addiction  involving  alcohol  or  drugs  other  than 
nicotine/ 

Consequences  of  Risky  Substance 
Use  and  Untreated  Addiction 

A  broad  range  of  health  and  social  consequences 
result  from  risky  substance  use  and  addiction, 
including  those  discussed  above  for  special 
populations.96  Risky  substance  use  and 
addiction  constitute  the  largest  preventable 
public  health  problems  and  the  leading  causes  of 
preventable  death  in  the  U.S.97  Of  the  nearly  2.5 
million  deaths  in  2009,  an  estimated  minimum 
of  578,819  were  attributable  to  tobacco,  alcohol 
or  other  drugs.5  98  (Table  3.8) 


'  They  had  a  history  of  using  illicit  drugs  regularly, 
met  clinical  criteria  for  addiction,  were  under  the 
influence  of  alcohol  or  other  drugs  when  they 
committed  their  crime,  had  a  history  of  alcohol 
treatment,  were  incarcerated  for  an  alcohol  or  other 
drug  law  violation,  committed  their  offense  to  get 
money  to  buy  drugs  or  had  some  combination  of 
these  characteristics. 

*  Due  to  data  limitations,  the  estimated  rate  of 
addiction  in  the  adult  inmate  population  does  not 
include  nicotine  dependence.  However,  other 
research  suggests  that  the  rate  of  tobacco  use  in  the 
justice  population  is  higher  than  in  the  general 
population.  For  example,  in  2005,  37.8  percent  of 
state  inmates  and  38.6  percent  of  federal  inmates 
smoked  in  the  month  of  their  arrest.  In  contrast,  the 
current  smoking  rate  in  the  general  population  at  that 
time  was  approximately  10  percentage  points  lower 
(24.9  percent). 

§  These  numbers  do  not  reflect  the  share  of  deaths 
from  a  wide  range  of  other  health  conditions 
attributable  to  risky  substance  use  and  addiction. 


-55- 


Table  3.8 

Deaths  Attributable  to  Substance  Use 


Deaths/Year 

Total  Deaths  Attributable  to 

578,819 

Substance  Use 

Tobacco 

443,000 

Alcohol 

98,334 

Other  drugs 

37,485* 

Based  on  data  from  2009. 
Sources:  Tobacco— Centers  for  Disease  Control  and 
Prevention  (2008);  Alcohol-CASA  Columbia 
analysis  of  the  Alcohol  and  public  health:  Alcohol- 
Related  Disease  Impact  (ARDI)  (2012);  Other 
Drugs— Centers  for  Disease  Control  and  Prevention 
(2010);  Kochanek,  K„  et  al.  (2011).  

Four  out  of  every  10  (39.6  percent)  fatal  traffic 
crashes  involve  a  driver  who  is  under  the 
influence  of  alcohol  or  who  tested  positive  for 
other  drugs. 


Overdose  deaths  caused  by  controlled 
prescription  drugs  and  illicit  drugs  have 


increased  five-fold  since  1990luuand  now 
surpass  the  total  number  of  deaths  caused  by 


traffic  accidents. 


101 


Individuals  with  addiction  are  at  increased  risk 
of  potentially  fatal  diseases  including  cancer,102 
heart  disease103  and  sexually-transmitted 
diseases.104  More  specifically,  smoking 
contributes  to  multiple  types  of  cancer  as  well  as 
heart  and  respiratory  disease.105  Alcohol 
contributes  to  some  of  the  leading  causes  of 
death,  including  heart  disease,  cancer  and  stroke, 
as  well  as  to  other  serious  illnesses  such  as 
cirrhosis,  hepatitis  and  pancreatitis.106  Injection 
drug  use  contributes  to  HIV,  hepatitis  C  and 
hepatitis  B.107  CASA  Columbia's  research 
found  that  risky  substance  use  and  addiction 
cause  or  contribute  to  more  than  70  other 
conditions  requiring  medical  care,  including 
cancer,  respiratory  disease,  cardiovascular 
disease,  pregnancy  complications,  HIV/AIDS, 
cirrhosis,  ulcers  and  trauma.108  (See  Table  3.9) 


The  many  negative  consequences  of  our  failure 
to  prevent  risky  substance  use  and  treat 
addiction  extend  beyond  the  individual  to 
family,  friends,  community  and  society.109 
Risky  substance  use  and  untreated  addiction 
contribute  to  family  dysfunction  and  financial 
troubles,  disrupted  social  relationships,  unsafe 
sexual  practices,  unplanned  pregnancies,  lost 
work  productivity,  legal  problems,  poor 
academic  and  career  performance, 
homelessness,  property  and  violent  crimes, 
domestic  violence,  child  abuse  and  neglect, 
rapes  and  other  sexual  assaults  and  motor 
vehicle  crashes  and  fatalities. 


no 


Risky  substance  use  and  addiction  adversely 
affect  the  mental  health  of  other  family  members 
as  well.  Family  members  ages  1 9  and  older  are 
at  approximately  twice  the  risk  of  having 
addiction  or  clinical  depression  as  those  ages  1 9 
and  older  in  families  without  a  member  with 
addiction,  and  they  have  higher  health  care 
costs.111 

Children  and  adolescents  are  particularly 
vulnerable  to  the  health  consequences  of 
substance  use. 1 12  Approximately  70  percent  of 
child  welfare  cases  are  caused  or  exacerbated  by 
parental  risky  use  and  addiction.113  Children 
exposed  to  parental  substance  use  are  at 
increased  risk  of  emotional  and  behavioral 
problems,  conduct  disorder,  poor  developmental 
outcomes  and  risky  substance  use  and  addiction 
in  adolescence  and  adulthood.114  Children  and 
adolescents  with  family  members  who  have 
addiction  are  more  likely  to  be  diagnosed  with  a 
number  of  medical  conditions,  including  asthma, 
depression,  headaches,  attention  deficit/ 
hyperactivity  disorder,  trauma  and  addiction, 
than  children  in  families  of  similar  demographic 
characteristics  who  do  not  have  a  member  with 
addiction.115 


Has  a  blood  alcohol  concentration  of  0.08  or  higher. 


-56- 


Table  3.9 

Conditions  Requiring  Medical  Care  Attributable  to  Risky  Use  and  Addiction 


Tobacco-Related  Conditions 

Malignant  neoplasm  (Cancer) 

Cardiovascular  disease 

Perinatal  conditions 

Lip,  oral  cavity,  pharynx 

Ischemic  heart  disease 

Short  gestation,  low  birth  weight 

Esophagus 

Other  heart  disease 

Respiratory  distress  syndrome 

Stomach 

Cerebrovascular  disease 

Other  respiratory 

Pancreas 

Aortic  aneurysm 

Larynx 

Other  circulatory  disease 

Trachea/lung/bronchus 

Respiratory  diseases 

Cervix  uteri 

Pneumonia,  influenza 

Kidney  and  renal  pelvis 

Bronchitis,  emphysema 

Urinary  bladder 

Chronic  airway  obstruction 

Acute  myeloid  leukemia 

Alcohol-Related  Conditions 

Acute  pancreatitis 

Laryngeal  cancer 

Acute  Conditions 

Alcohol  abuse/Alcohol  dependence  syndrome 

Liver  cancer 

Air-space  transport 

Alcohol  cardiomyopathy 

Liver  cirrhosis  unspecified 

Alcohol  poisoning 

Alcohol  polyneuropathy 

Oropharyngeal  cancer 

Aspiration 

Alcohol-induced  chronic  pancreatitis 

Portal  hypertension 

Child  maltreatment 

Alcoholic  gastritis 

Prostate  cancer  (males  only) 

Drowning 

Alcoholic  liver  disease 

Psoriasis 

Excessive  blood  alcohol  level 

Alcoholic  myopathy 

Spontaneous  abortion  (females  only) 

Fall  injuries 

Alcoholic  psychosis 

Stroke  hemorrhagic 

Fire  injuries 

Breast  cancer  (females  only) 

Stroke  ischemic 

Firearm  injuries 

Cholelithiases 

Supraventricular  cardiac  dysrhythmia 

Homicide 

Chronic  hepatitis 

Hypothermia 

Chronic  pancreatitis 

Prenatal,  infant 

Motor-vehicle  non-traffic  crashes 

Degeneration  of  nervous  system  due  to  alcohol 

Birth  trauma 

Motor-vehicle  traffic  crashes 

Epilepsy 

Digestive 

Occupational  and  machine  injuries 

Esophageal  cancer 

Hemorrhage/hemolysis/endocrine/ 
jaundice/hematologic 

Other  road  vehicle  crashes 

Esophageal  varices 

Hypoxia/asphyxia/respiratory 

Poisoning  (not  alcohol) 

Fetal  alcohol  syndrome 

Infections 

Suicide 

Gastro  esophageal  hemorrhage 

Integument/temperature  regulation 

Water  transport  accident 

Hypertension 

Length  of  gestation  and  fetal  growth 

Ischemic  heart  disease 

Low  birth  weight/prematurity/ 
intrauterine  growth  restriction  death 

Other  Drug-Related  Conditions* 

Drug-induced  psychosis 

HIV/AIDS 

Other  infectious  diseases 

Hepatitis 

Inflammatory  and  toxic  neuropathy 

*  Other-drug  related  conditions  also  may  include  kidney,  liver  and  respiratory  diseases  as  well  as  the  accident,  suicide  and  poisoning 

categories  listed  above  in  the  Alcohol-Related  Conditions  section. 

Sources:  Centers  for  Disease  Control  and  Prevention.  (2004b);  Centers  for  Disease  Control  and  Prevention.  (2008a);  Centers  for  Disease 

Control  and  Prevention.  (2008b);  Merrill,  J.  &  Fox,  K.  (1998);  The  National  Center  on  Addiction  and  Substance  Abuse  (CASA)  at 

Columbia  University.  (1993);  The  National  Center 

on  Addiction  and  Substance  Abuse  (CASA)  at  Columbia  University.  (1994). 

-57- 


Tobacco 

Tobacco  use  is  the  leading  preventable  cause  of 
death  and  disability  in  the  United  States.  An 
estimated  one  in  five,  or  443,000,  deaths  each 
year  are  attributable  to  cigarette  smoking  and 
exposure  to  tobacco  smoke;116  nearly  400,000 
deaths  per  year  are  attributable  to  smoking- 
related  diseases.1  7  (Table  3.10) 


Table  3.10 

Average  Tobacco- Attributable  Deaths  Due  to 
Smoking-Related  Disease  in  the 
United  States,  2000-2004 
 Select  Examples"  


Average  Deaths 

Per  Year 

total 

392,683 

Cancers: 

160,848 

Lung,  trachea,  bronchus 

125,522 

Esophagus 

8,592 

Pancreas 

6,683 

Urinary  bladder 

4,983 

Lip,  oral  cavity,  pharynx 

4,893 

Kidney,  renal  pelvis 

3,043 

Larynx 

3,009 

Stomach 

2,484 

Acute  myeloid  leukemia 

1,192 

Cervix,  uterus  (females  only) 

447 

Cardiovascular  Diseases: 

128,497 

Ischemic  heart  disease 

80,005 

Other  heart  disease 

21,004 

Cerebrovascular  disease 

15,922 

Aortic  Aneurysm 

8,419 

Atherosclerosis 

1,893 

Other  arterial  disease 

1,254 

Respiratory  Diseases: 

392,683 

Chronic  airway  obstruction 

78,988 

Bronchitis,  emphysema 

13,927 

Pneumonia,  influenza 

10,423 

These  data  do  not  reflect  all  tobacco-attributable  deaths. 
For  example,  deaths  due  to  secondhand  smoke  and  fire 
burn  are  not  included. 

Source:  Centers  for  Disease  Control  and  Prevention 


(2011). 


Although  the  prevalence  of  tobacco  use  has 
declined  over  the  past  two  decades,121  mortality 
rates  have  remained  constant  due  to  an  increase 
in  population  size,  the  identification  of  new 
diseases  linked  to  smoking  and  the  fact  that 
cohorts  that  smoked  heavily  during  their  lifetime 
are  now  reaching  an  age  with  the  highest 
incidence  of  smoking-attributable  diseases.122 

Over  approximately  the  past  four  decades,*  an 
estimated  94,000  infant  deaths  have  been  linked 
to  prenatal  exposure  to  smoking.123  Pregnant 
women  who  smoke  put  their  babies  at  increased 
risk  for  a  host  of  health  problems  including 
placenta  previa, '  stillbirth  and  sudden  infant 
death  syndrome  (SIDS).124  Smoking  during 
pregnancy  increases  the  risk  for  preterm  birth125 
and  pregnant  smokers  are  1.6  times  more  likely 
to  have  a  low  birth  weight  baby  than  pregnant 
nonsmokers  (1 1.9  percent  vs.  7.5  percent).126 
Merely  reducing  the  number  of  cigarettes 
women  smoke  during  pregnancy  results  in  birth 
weight  gain;  but  even  light  smokers*  are  twice  as 
likely  as  nonsmokers  to  have  low  birth  weight 
infants. §  127  Low  birth  weight  is  a  leading  risk 
factor  for  neonatal  and  infant  mortality,  can 
result  in  restricted  childhood  development  and 
increases  the  risk  of  chronic  disease, 
developmental  delays  and  cognitive 

1 7  8 

impairment. 

The  negative  long-term  health  consequences  for 
children  exposed  to  prenatal  smoking  include 
increased  risk  for  substance-related  problems, 
depression,129  attention  deficit/hyperactivity 
disorder,  conduct  disorders  and  childhood 
obesity.130  The  nicotine  in  tobacco  products  can 
produce  structural  and  chemical  changes  in  the 
developing  adolescent  brain  and  make  young 
people  who  smoke  vulnerable  to  future  addiction 
and  to  certain  forms  of  mental  illness,  including 
panic  attacks,  panic  disorder  and  other  anxiety 
disorders.131 


Tobacco  use  contributes  to  approximately  30 
percent  of  cancer  and  heart  disease-related 
deaths118  and  numerous  other  health  conditions 
including  respiratory  illness  and  chronic  kidney 
disease.119  An  estimated  8.6  million  Americans 
suffer  from  a  serious  smoking-related  illness.120 


*  1964  to  2004. 

'  The  complete  or  partial  obstruction  of  the  cervical 
opening  by  the  placenta. 

*  Smoke  less  than  half  a  pack  a  day. 

§  In  a  study  of  low-income  black  women. 


-58- 


There  also  are  serious  health  consequences  for 
nonsmokers  exposed  to  environmental  tobacco 
smoke  (ETS).132  Children  exposed  to  ETS  are  at 
increased  risk  of  developing  acute  lower 
respiratory  infections,  ear  infections,  asthma  and 
chronic  respiratory  symptoms,133  and  of 
becoming  smokers  and  developing  asthma  in 
adulthood.134  Exposure  to  ETS  increases  the 
risk  of  lung,  breast  and  other  cancers,  heart 
disease,  stroke  and  respiratory  illnesses.135 

Recently,  the  term  "third-hand  smoke"  has  been 
developed  to  describe  the  invisible  but  toxic 
gases  and  particles— including  heavy  metals, 
carcinogens  and  radioactive  materials— that  form 
a  residue  on  smokers'  hair,  clothing  and 
household  items  and  remain  for  weeks  or 
months  after  the  second-hand  smoke  has 
cleared.136  Like  second-hand  smoke,  third-hand 
smoke  is  a  cancer  risk.137 

Alcohol 

Alcohol  use  is  the  third  leading  cause  of  death  in 
the  United  States  (after  tobacco  use  and  poor 
diet/physical  inactivity)  and  is  responsible  for 
approximately  3.5  percent  of  all  deaths.138  An 
estimated  98,334  people  die  from  alcohol- 
related  causes  in  the  U.S.  each  year,  including 
chronic  diseases  (e.g.,  liver  disease,  cancer)  and 
acute  causes  (e.g.,  accidents,  homicides).139 
(Table  3.11) 

Of  the  13,555  substance-related  traffic  fatalities 
in  2009,  10,185  involved  drivers  who  were 
alcohol  impaired  (BAC  of  .08  or  higher).140 
Young  people  are  at  greater  risk  of  becoming  a 
victim  of  an  alcohol-related  traffic  fatality 
compared  to  older  people.141  In  2009,  35 
percent  of  21-  to  24-year  old  drivers  involved  in 
fatal  motor  vehicle  traffic  crashes  were  under  the 
influence  of  alcohol,  more  than  any  other  age 
group.'  142 


*  Had  a  BAC  of  .08  or  higher. 

1  Compared  to  19  percent  of  15-  to  20-year  olds; 

33  percent  of  25-  to  29-year  olds;  29  percent  of  30-  to 

34-year  olds;  26  percent  of  35-  to  44-year  olds;  22 

percent  of  45-  to  54-year  olds;  13  percent  of  55-  to 

64-year  olds;  and  7  percent  of  65-  to  74-year  olds. 


Table  3.11 

Average  Alcohol-Attributable  Deaths  in  the 
United  States  2001-2005, 
Select  Examples 


Average  Deaths 

Per  Year 

Total 

98,334 

Chronic  Causes; 

Alcoholic  liver  disease 

12,219 

Stroke  hemorrhagic 

8,725 

Liver  cirrhosis,  unspecified 

7,055 

Esophageal  cancer 

4,225 

Alcohol  denendence  svndrome 

3,857 

Liver  cancer 

3,431 

Breast  cancer  (females  only) 

1,835 

Oropharyngeal  cancer 

1,528 

Laryngeal  cancer 

1,460 

Hypertension 

1,480 

Prostate  cancer  (males  only) 

1,025 

Acute  Causes: 

Motor-vehicle  traffic  crashes 

13,819 

Homicide 

7,787 

Suicide 

7,235 

Fall  injuries 

5,532 

Poisoning  (not  alcohol) 

5,416 

Fire  injuries 

1,158 

Drowning 

868 

Alcohol  poisoning 

370 

Hypothermia 

269 

Aspiration 

204 

Child  maltreatment 

168 

Source:  CASA  Columbia  analysis  of  the  Alcohol  and 
public  health:  Alcohol-Related  Disease  Impact  (ARDI). 

In  2009,  alcohol  was  reported  in  at  least  one- 
quarter  (24.3  percent)  of  substance-related 
emergency  department  (ED)  visits. 1  These 
reports,  however,  significantly  underestimate  the 
prevalence  of  alcohol-related  emergency 
department  visits  for  two  reasons:  the  data  set 
does  not  include  visits  linked  to  alcohol  use  in 
combination  with  other  drugs  for  persons  under 
the  age  of  2 1 ,  and  many  EDs  do  not  screen  for 


*  Measured  in  terms  of  patient  visits,  not  individual 
drug  reports.  The  analyses  of  the  Substance  Abuse 
and  Mental  Health  Services  Administration,  Drug 
Abuse  Warning  Network  (DAWN)  data  assess  the 
number  of  drug  mentions  associated  with  a  drug- 
related  emergency  department  visit;  up  to  four  drugs 
plus  alcohol  may  be  recorded  for  each  drug-related 
visit. 


-59- 


substance  use  because  of  state  laws  that  exclude 
alcohol  and  other  drug-related  injuries  from 
medical  insurance  coverage.*  143 

Risky  alcohol  use  and  addiction  involving 
alcohol  are  associated  with  neurological 
problems  including  dementia,  stroke  and 
neuropathy;144  cardiovascular  problems 
including  myocardial  infarction, 
cardiomyopathy,  atrial  fibrillation  and 
hypertension;145  psychiatric  problems  including 
depression,  anxiety  and  suicide;146  liver  diseases 
including  hepatitis  and  cirrhosis;147  and 
gastrointestinal  problems  including  pancreatitis 
and  gastritis. 148  Other  associated  conditions 
include  increased  risk  of  cancer  of  the  liver, 
breast,  mouth,  throat,  esophagus  and  colon,149 
and  recent  research  suggests  that  risky  alcohol 
use  may  contribute  to  the  physiological  process 
that  causes  cancer  cells  to  metastasize.150 

Heavy  alcohol  use  during  pregnancy  is 
associated  with  miscarriage  and  stillbirth  and  is 
one  of  the  primary  causes  of  severe  mental  and 
developmental  delays  in  infants.151  Fetal  alcohol 
syndrome  (FAS)  is  the  leading  known  cause  of 
preventable  mental  retardation.152 

Illicit  Drugs 

In  2008,'  there  were  an  estimated  16,044  deaths 
attributed  to  the  use  of  illicit  drugs.153  Of  the 
13,555  substance-related  traffic  fatalities  in 
2009,  5,938  involved  drivers  impaired  either  by 
illicit  drugs  alone  (3,146  deaths)  or  illicit  drugs 
in  combination  with  alcohol  (2,792  deaths).154 

In  2009,  illicit  drugs  were  involved  in  an 
estimated  973,591  emergency  department 
visits;*  accounting  for  35.9  percent  of  substance- 
related  ED  visits;155  cocaine,  marijuana  and 


*  In  25  states,  Uniform  Accident  and  Sickness  Policy 
Provision  Laws  (UPPL)  exclude  alcohol  and  other 
drug-related  injuries  from  medical  insurance 
coverage,  creating  a  barrier  to  conducting  screening 
for  risky  substance  use  (see  Chapters  IV  and  X). 

'  Most  recent  available  data  that  distinguishes 
between  illicit  and  controlled  prescription  drugs. 

*  Measured  in  terms  of  patient  visits,  not  individual 
drug  reports. 


heroin  were  the  most  frequently  mentioned  illicit 
drugs.156 

Injection  drug  use  behavior— including  sharing 
needles  and  other  injection  paraphernalia—is 
associated  with  the  spread  of  HIV/AIDS.157  It  is 
estimated  that  more  than  one-third  of  all  AIDS- 
related  deaths  in  the  U.S.  have  occurred  among 
illicit  drug  users  and  their  sexual  partners.158 

Morbidity  (secondary  illness)  and  mortality 
(death)  data  related  to  illicit  drug  use  may 
represent  the  direct  pathological  effects  or 
medical  toxicities  from  the  drug  (e.g.,  cocaine 
producing  seizures  or  strokes  or  inhalants 
producing  cardiac  arrhythmias  that  can  lead  to 
sudden  cardiac  deaths),  but  also  the  infections 
transmitted  via  drug  self-administration  (e.g., 
intravenous  or  intramuscular  self- 
administration). 159 

Marijuana  use  is  associated  with  sexually 
transmitted  disease  due  to  unsafe  sexual 
behaviors  engaged  in  while  under  the  influence 
of  the  drug,  bronchitis  and  lung  cancer;  cocaine 
use  is  associated  with  pancreatitis;  heroin  use  is 
associated  with  hepatitis  and  tuberculosis; 
hallucinogen  use  is  associated  with  tinnitus  and 
sexually  transmitted  disease;  and  inhalant  use  is 
associated  with  HIV/AIDS,  sexually  transmitted 
disease,  tuberculosis,  bronchitis,  asthma, 
sinusitis  and  tinnitus.5  160 

Illicit  drug  use  also  is  linked  to  mental  health 
problems.  Marijuana  use  is  associated  with  the 
onset  of  psychotic  disorders,  particularly  in 
individuals  with  an  underlying  vulnerability  to 
the  illness;161  several  longitudinal  studies  have 
linked  marijuana  use  with  the  subsequent  onset 
of  schizophrenia,  and  case  studies  have  linked 
synthetic  cannabinoids  with  psychosis.162 
Marijuana  and  inhalant  use  are  associated  with 


These  health  consequences  are  associated  primarily 
with  long-term  use  of  illicit  drugs.  The  analyses 
adjusted  for  potentially  confounding  factors  such  as 
the  duration  of  controlled  prescription  drug  misuse, 
alcohol  use,  tobacco  use,  daily  cigarette  smoking 
history  and  demographic  variables  (age,  gender, 
race/ethnicity,  educational  attainment,  health 
insurance  status  and  family  income). 


-60- 


anxiety  and  depression,  and  cocaine  and  heroin 
use  are  associated  with  anxiety.*  163 

Methamphetamine,  cocaine  and  other  stimulant 
use  (including  the  use  of  amphetamine-related 
and  other  "designer  drugs")  are  associated  with 
violent  behavior,  hallucinations,  paranoia  and 
delusions  which  can  be  acute  time-limited 
symptoms  or  which  can  persist  long  after  the 
cessation  of  use.f  164  There  is  a  range  of 
substance-induced  disorders  included  in  the 
DSM-IV  that  reflect  secondary  mental  health 
effects  of  addictive  substance  use.165 

Approximately  160,000  pregnancies  in  2004 
were  associated  with  illicit  drug  use.166  Illicit 
drug  use  during  pregnancy  increases  the  risk  of 
neurological  and  cognitive  deficits  in  the  fetus 
and  future  behavior  problems.167  Heavy 
marijuana  use  has  been  associated  with  low  birth 
weight,  premature  delivery  and  complications  in 
delivery.168  Marijuana  and  cocaine  exposure 
have  been  linked  to  impaired  attention,  language 
and  learning  skills,  as  well  as  to  behavioral 
problems.169 

Infants  exposed  to  prenatal  illicit  drug  use  are  at 
increased  risk  of  low  birth  weight,170 
developmental  and  educational  problems  and 
future  substance  use  and  addiction.171 

Controlled  Prescription  Drugs 

In  2008/  there  were  an  estimated  20,044 
overdose  deaths5  attributable  to  risky  use  of 
controlled  prescription  drugs.  The  majority  of 
these  deaths  (73.8  percent  or  14,800)  were 
attributable  to  the  risky  use  of  prescription 
opioids.172  Overdose  deaths  from  controlled 
prescription  drugs  have  increased  significantly 


over  recent  years  and  now  surpass  the  number  of 
overdose  deaths  caused  by  illicit  drugs.** 173 


Enough  prescription  painkillers  were  prescribed 
in  2010  to  medicate  every  American  adult 
around-the-clock  for  a  month. 174 

—Centers  for  Disease  Control  and  Prevention 


In  2009,  there  were  224  deaths  that  involved 
drivers  impaired  by  controlled  prescription  drugs 
(or  an  unknown  combination  of  prescription 
drugs,  alcohol  and  other  drugs).175  The  risky  use 
of  controlled  prescription  drugs  was  involved  in 
an  estimated  1,079,683  emergency  department 
visits,' f  accounting  for  39.8  percent  of  all 
substance-related  emergency  department  visits 
in  the  U.S.  Among  prescription  drug-related  ED 
visits,  73.3  percent  involved  opioids,  stimulants, 
sedatives  and  barbiturates.1*  176 

The  risky  use  of  prescription  opioids  can  result 
in  a  range  of  consequences  from  drowsiness  and 
constipation  to  depressed  breathing,  at  high 
doses.  Even  a  large  single  dose  of  opioids  can 
lead  to  severe  respiratory  depression  or  death.177 
One  study  found  that  individuals  with  addiction 
involving  opioids  had  significantly  higher  rates 
of  comorbid  health  conditions,  including 
hepatitis,  pancreatitis  and  psychiatric  illness  than 
those  without  addiction  involving  opioids.178 

At  high  doses,  risky  use  of  prescription 
stimulants  can  produce  anxiety,  paranoia, 
seizures179  and  serious  cardiovascular 
complications  including  stroke.180  Other 
possible  adverse  effects  include  slowed  growth 
in  children,  allergic  reactions,  potentially  fatal 
interactions  with  other  drugs§§  and  sudden 
death.181 


*  Adjusting  for  potentially  confounding  factors  such 
as  those  listed  above. 

'  Producing  what  is  described  in  the  DSM-IV  as  a 
Substance-Induced  Mental  Disorder. 

*  Most  recent  available  data  that  distinguishes 
between  illicit  and  controlled  prescription  drugs. 

§  Data  on  other  causes  of  death  (e.g.,  accidents)  that 
are  attributable  to  the  misuse  of  controlled 
prescription  drugs  are  not  available. 


Specifically,  heroin  and  cocaine. 
^  Measured  in  terms  of  patient  visits,  not  individual 
drug  reports. 

t+  The  remaining  prescription  drug-related  ED  visits 
involved  antidepressants  and  antipsychotics  (12.3 
percent)  or  other  types  of  prescription  drugs  (14.4 
percent). 

§§  Such  as  MAO  inhibitors. 


-61- 


Long-term  risky  use  of  benzodiazepines  is 
associated  with  cognitive  impairment,  other 
adverse  effects  and  a  high  risk  of  drug 
interactions,  addiction  and  withdrawal  syndrome 
that  can  be  life  threatening.182  Likewise,  risky 
use  of  barbiturates,  such  as  butalbital  and 
phenobarbital,  can  lead  to  changes  in  alertness, 
irritability  and  memory  loss.183  If  combined 
with  certain  medications  or  alcohol,  tranquilizers 
and  sedatives  can  slow  both  heart  rate  and 
respiration,  which  can  be  fatal.184 

Taking  certain  controlled  prescription  drugs 
during  pregnancy,  such  as  alprazolam  (Xanax) 
or  phenobarbital,  may  harm  the  developing 


Chapter  IV 

Screening  and  Early  Intervention 


Nearly  one-third  (31.7  percent)  of  the  U.S. 
population  (80.4  million  people  ages  12  and 
older)  engages  in  substance  use  that  threatens 
their  own  health  or  safety  or  the  health  and 
safety  of  others,  but  does  not  meet  clinical 
diagnostic  criteria  for  addiction. 1  Few  of  these 
individuals,  however,  are  routinely  screened  for 
risky  use  of  addictive  substances  or  receive  any 
services  designed  to  reduce  such  use  such  as 
brief  interventions.2  Of  those  who  do  receive 
some  form  of  screening,  in  most  cases  it 
involves  only  one  type  of  substance  use- 
tobacco  or  alcohol— which  fails  to  identify  risky 
use  of  other  substances  or  recognize  that  30.6 
percent  of  risky  users  who  are  not  addicted 
engage  in  risky  use  of  more  than  one  substance.3 

In  order  to  reduce  risky  use  and  its  far-reaching 
health  and  social  consequences,  which  may 
include  the  development  of  addiction,  health 
care  practitioners  must:4 

•  Understand  the  risk  factors,*  how  these  risks 
vary  across  the  lifespan  and  how  risky  use— 
whether  or  not  it  progresses  to  addiction- 
can  have  devastating  outcomes  for 
individuals,  families  and  communities; 

•  Educate  patients,  and  their  families  if 
relevant,  about  these  risks  and  the  adverse 
consequences  of  risky  use; 

•  Screen  for  risky  use  of  addictive  substances 
and  related  problems  using  tools  that  have 
been  proven  to  be  effective;  and 

•  Provide  brief  intervention  when  appropriate. 

Health  care  practitioners  also  should  conduct 
further  assessment  if  the  patient  presents  with 
signs  or  symptoms  of  addiction  and  treat  the 
patient  or  provide  referrals  to  specialty  care  if 
needed,  as  discussed  in  Chapters  V  and  VI. 


See  Chapter  II. 


-63- 


Screening  and  early  intervention  services  should 
be  provided  in  regular  health  care  settings,  but 
also  can  be  highly  successful  when  offered  in 
other  venues  to  individuals  at  high  risk, 
including  students,  those  in  justice  programs  and 
those  in  social  service  settings.  To  assure  that 
these  health  care  services  are  provided,  a  range 
of  barriers  must  be  addressed,  including 
insufficient  training  of  health  care  and  other 
professionals  and  a  lack  of  trained  specialty 
providers  to  which  patients  with  addiction  can 
be  referred  for  treatment;  time  constraints  and 
insufficient  financial  and  workforce  resources; 
and  screening  tools  that  may  fail  to  detect  cases 
of  risky  use  of  addictive  substances. 

The  Need  for  Patient  Education, 
Screening  and  Intervention 
throughout  the  Lifespan 

For  many  health  conditions,  certain 
developmental  periods  are  associated  with 
increased  risk  of  acquiring  a  disease.5 
Addiction,  in  most  cases,  has  its  roots  in 
adolescence  with  the  initiation  of  risky  use  of 
addictive  substances,6  but  the  onset  of  risky  use 
and  addiction  can  occur  at  any  point  in  the 
lifespan.  Each  life  phase  presents  unique 
vulnerabilities  that  must  be  recognized,  as  well 
as  the  basic  risk  factors  (discussed  in  Chapter  II) 
that  may  be  present  at  any  time  in  life. 

Childhood  and  Adolescence 

Adolescence  is  the  critical  period  for  the  onset 
of  substance  use  and  its  consequences,* 7  but 
signs  of  risk  sometimes  can  be  observed  much 
earlier.  In  addition  to  the  overall  risks 
associated  with  substance  use,  children  and 
adolescents  with  heightened  risk  of  engaging  in 
substance  use,  of  experiencing  the  adverse 
consequences  of  risky  use  and  of  developing 
addiction  include: 

•    Those  with  certain  genetic  predispositions  or 
structural  or  functional  brain  characteristics 
that  make  them  more  susceptible  to 
addictive  substances;8 


See  Chapter  II. 


•  Young  children  whose  temperaments'  are 
more  active,  impatient,  aggressive  and  non- 
conforming than  their  peers,9 

•  Those  with  behavioral  disorders  including 
oppositional  defiant  disorder'  and  conduct 
disorder/  10  those  who  engage  in  bullying5  11 
and  those  who  have  sleep  problems;**  12  and 

•  Children  who  are  maltreated,  abused  or  have 
suffered  other  trauma.13 

As  children  age,  moving  through  elementary  and 
middle  school-a  period  that  coincides  with  first- 
time  exposure  to  cigarettes  and  other  drugs— they 
are  presented  with  increasing  academic  and 
social  challenges  and  responsibilities  that 
increase  their  risk  of  trying  addictive  substances 
and  engaging  in  substance  use.14 

During  adolescence  and  into  early  adulthood  the 
brain  undergoes  considerable  developmental 
changes,  explaining  why  adolescence  is  such  a 
risky  period  for  the  onset  of  substance  use  and 
addiction.15  Hormonal  changes  that  occur 
during  adolescence  also  pose  a  biological  risk 
for  substance  use  in  this  age  group.  The  surge  in 
the  female  hormone  estrogen  and  the  male 
hormone  testosterone  during  puberty  is 
associated  with  risk  taking  and  sensation 


According  to  the  American  Academy  of  Child  and 
Adolescent  Psychiatry,  oppositional  defiant  disorder 
refers  to  a  pattern  of  disobedient,  hostile  and  defiant 
behavior  directed  toward  authority  figures.  Common 
behavioral  symptoms  include  defiance,  spitefulness, 
negativity,  hostility  and  verbal  aggression. 
*  Conduct  disorder  is  diagnosed  in  youth  who  exhibit 
enormous  difficulty  following  rules  and  behaving  in  a 
socially-acceptable  manner.  These  children  may 
bully  others,  start  fights,  show  aggression  toward 
animals,  steal  or  engage  in  sexually  inappropriate 
behavior. 

§  Past-year  participation  in  the  following  acts:  (a)  hit 
and  pushed  or  threatened  another  student,  (b)  called 
another  student  mean  names,  (c)  told  another  student 
you  will  not  like  her/him  unless  she/he  did  what  you 
wanted,  (d)  made  people  not  like  another  student,  (e) 
told  lies  or  spread  rumors  about  another  student,  (f) 
not  let  another  student  be  in  your  group  of  friends. 

Mothers'  reports  of  children  and  teens  having 
trouble  sleeping  and  overtiredness. 


-64- 


seeking.  The  lack  of  fully  developed  decision- 
making and  impulse-control  skills  combined 
with  the  hormonal  changes  of  puberty 
compromise  an  adolescent's  ability  to  assess 
risks  and  make  them  uniquely  vulnerable  to 
substance  use.16 

Other  psychological  and  social  challenges  faced 
by  adolescents— such  as  the  struggle  to  develop  a 
sense  of  identity,  feeling  less  satisfied  with  one's 
appearance  and  experiencing  peer  pressure  to 
conform— contribute  to  the  risk.  7 

Young  Adulthood 

In  recent  years,  researchers  have  begun  to 
recognize  the  developmental  stage  of  young 
adulthood— often  referred  to  as  emerging 
adulthood-as  a  period  of  life  that  is  strongly 
associated  with  risky  use.18  Young  adults  facing 
heightened  risk  include: 

•  College  students-*  -while  approximately 
two-thirds  of  college  students  who  engage  in 
substance  use  began  to  smoke,  drink  or  use 
other  drugs  in  high  school  or  earlier,  the 
culture  on  many  college  campuses  permits 
and  promotes  risky  use  rather  than  curtailing 
it.19 

•  Young  adults  facing  work-related  stress  or 
instability  in  living  arrangements,  social 
relations  or  academic  or  career  choices.20 
As  marriage  and  parenthood  have  become 
delayed,  the  phase  of  life  devoted  to 
academics  and  career  development  has 
stretched  well  into  the  twenties.  Young 
adults  may  turn  to  addictive  substances  to 
relieve  these  forms  of  stress  and  self- 
medicate  their  anxiety  and  emotional 
troubles.21 

Middle  and  Later  Adulthood 

Major  life  events  and  transitions  increase  the 
chances  that  an  individual  will  engage  in  risky 
use  of  addictive  substances.22  Adults  may  turn 
to  risky  use  when: 


Much  of  the  research  conducted  on  young  adults  is 
based  on  college  student  samples. 


•  Coping  with  the  stresses  of  child  rearing, 
balancing  a  career  with  family  and 
managing  a  household;23 

•  Facing  divorce,  caring  for  an  adult  family 
member  or  grandchildren  or  coping  with  the 
death  of  a  loved  one;24 

•  Struggling  with  retirement,  the  loss  of 
independent  living  or  financial  problems;25 
or, 

•  Coping  with  an  illness,  including  increasing 
physical  ailments  such  as  arthritis  or  other 
forms  of  chronic  pain.26 

Middle  aged  and  older  adults  who  engage  in 
risky  use  may  be  even  more  vulnerable  to  the 
health  consequences  of  such  use  since  physical 
tolerance  for  alcohol  and  other  drugs  declines 
with  age:  the  ways  in  which  addictive 
substances  are  absorbed,  distributed, 
metabolized  and  eliminated  in  the  body  change 
as  people  get  older.27  With  regard  to  alcohol, 
several  biological  factors  account  for  reduced 
tolerance.  The  amount  of  lean  body  mass 
(muscle  and  bone)  and  water  in  older  adults' 
bodies  decreases  as  the  amount  of  fat  increases, 
with  less  water  to  dilute  the  alcohol.  Reduced 
liver  and  kidney  function  slows  down  the 
metabolism  and  the  elimination  of  alcohol  from 
the  body,  including  the  brain.  These  factors 
allow  the  effects  of  alcohol  to  take  hold  more 
quickly  and  depress  brain  function  to  a  greater 
extent  than  in  younger  people,  impairing 
physical  coordination  and  cognitive  function.28 

The  increasing  susceptibility  to  substance- 
induced  neurotoxicity  with  age  is  a  growing 
concern  as  the  "Boomer"  generation,  a 
population  with  higher  rates  of  risky  use,  ages.29 
The  interaction  of  prescribed  and  other  drugs 
with  alcohol  also  is  of  great  concern  for  the 
physical  and  mental  health  of  middle  and  older 
adults  who  are  likelier  than  younger  people  to 
use  prescription  and  over-the-counter 
medications.30 


-65- 


Attending  to  Co-occurring 
Conditions 

Individuals  who  engage  in  risky  use  or  who  have 
addiction  frequently  suffer  from  other  co- 
occurring  health  conditions.* 31  Therefore,  any 
attempt  to  identify  risky  use  of  addictive 
substances,  evaluate  an  individual's  risk  for 
developing  addiction  or  assess  a  substance 
user's  need  for  intervention  or  treatment  must 
involve  identification  of  co-occurring  conditions 
and  plans  to  address  them.  Being  informed  of  a 
patient's  health  conditions  that  might  be  caused 
or  exacerbated  by  substance  use  or  that  might 
cause  or  exacerbate  the  patient's  addiction  will 
help  medical  professionals  determine 
appropriate  interventions  and  provide  effective 
care.32  Similarly,  medical  professionals  treating 
patients  with  medical  conditions  that  frequently 
co-occur  with  risky  use  and  addiction- such  as 
hypertension,  gastritis  and  injuries— should  be 
prompted  to  screen  for  risky  use  of  addictive 
substances  that  may  cause  or  aggravate  these 
conditions. 


•     Steps  patients  can  take  to  prevent  risky  use 
of  addictive  substances  and  the  onset  of 
addiction,  e.g.,  by  delaying  initiation  of 
substance  use,  following  guidelines  for  the 
safe  use  of  alcohol  and  of  controlled 
prescription  medications,  being  vigilant  for 
signs  and  symptoms  of  risk  and  seeking 
professional  help  at  the  first  sign  of  trouble. 

Screening1 

Screening,  a  staple  of  public  health  practice  that 
dates  back  to  the  1930s,34  serves  to  identify  early 
signs  of  risk  for  or  evidence  of  a  disease  or  other 
health  condition  and  distinguish  between 
individuals  who  require  minimal  intervention 
and  those  who  may  need  more  extended 
treatment.35  It  is  an  effective  method  of 
preventive  care  in  many  medical  specialties,  and 
risky  use  of  addictive  substances  is  no 
exception.  Screening  for  risky  use  of  addictive 
substances  is  comparable  to  offering  regularly 
scheduled  pap  smears  or  colonoscopies  to 
identify  cancer  indicators.36 


Patient  Education  and  Motivation 


Educating  patients  and  motivating  them  to 
reduce  their  risky  use  of  addictive  substances  is 
a  critical  component  of  preventive  care.33  As 
part  of  routine  medical  practice,  medical  and 
other  health  professionals  should  educate  their 
patients  (and  parents  of  young  patients)  about: 


•  The  adverse  consequences  of  risky  use  and 
the  nature  of  addiction— that  it  is  a  disease 
that  can  be  prevented  and  treated 
effectively; 

•  The  risk  factors  for  substance  use,  tailoring 
the  information  to  the  patient's  age,  gender, 
mental  health  history  and  other  relevant 
medical,  social  and  demographic 
characteristics; 

•  Times  of  increased  risk  for  substance  use, 
such  as  adolescence,  key  life  transitions 
and  stressful  life  experiences;  and 


See  Chapter  II. 


'  Despite  the  distinction  between  screening  and 
assessment  tools,  the  term  screening  often  is  used  to 
subsume  the  concept  of  assessment  or 
interchangeably  with  the  term  in  the  clinical  and 
research  literatures.  Nevertheless,  Chapter  V 
addresses  assessments  specifically.  In  addition, 
while  there  is  some  overlap  between  screening  or 
assessment  procedures  used  to  identify  risky  use  of 
addictive  substances  and  methods  used  to  diagnose  a 
clinical  addiction,  a  formal  diagnosis  of  addiction  is 
based  on  the  demonstration  of  specific  symptoms 
included  in  the  most  recent  versions  of  the  Diagnostic 
and  Statistical  Manual  of  Mental  Disorders  (DSM)  or 
the  International  Statistical  Classification  of  Diseases 
(ICD).  (See  Chapter  II.) 


-66- 


It's  like  taking  a  blood  pressure.  You  don't  just 
take  the  pressure  of  patients  you  suspect  of 
having  high  blood  pressure.  You  take 
everyone 's  blood  pressure.  And,  with  public 
health  screening,  you  're  typically  not  shooting 
for  a  diagnosis,  but  just  an  initial  measure  of  a 
patient's  level  of  risk?* 

—Dan  Hungerford,  DrPH 
Epidemiologist 
National  Center  for  Injury 
Prevention  and  Control 
Centers  for  Disease  Control  and  Prevention 


Screening  tools  typically  are  brief  and  easy  to 
administer  and  are  to  be  implemented  with  a 
relatively  broad  population  to  identify 
indications  of  risk  involving  smoking,  drinking 
or  using  other  drugs.  Screening  tools  typically 
include  written  or  oral  questionnaires  and,  less 
frequently,  clinical  and  laboratory  tests.  (See 
Appendix  H  for  a  description  of  commonly-used 
screening  instruments.) 

An  instrument  that  can  be  used  to  screen  for 
risky  use  of  all  addictive  substances— rather  than 
separately  for  each  substance-and  that  makes 
appropriate  distinctions  for  young  people  and  by 
gender  has  yet  to  be  developed. 

In  recent  years,  attempts  have  been  made  to 
develop  and  validate  more  simple  screening 
tools  that  can  be  used  in  primary  care  settings. 
For  example: 

•  A  single-item  measure  of  current  tobacco 
use*  has  been  validated  on  adult  populations 
for  use  in  research  protocols37  but  also  can 
be  used  clinically  to  determine  if  a  patient  is 
a  current  smoker. 

•  The  National  Institute  on  Alcohol  Abuse  and 
Alcoholism  (NIAAA)  recommends  a  single- 
question  screening  test  for  unhealthy  alcohol 


Have  you  smoked  one  or  more  cigarettes  in  the  past 
month? 


use '  to  be  asked  of  patients  of  all  ages  who 
admit  to  sometimes  drinking  alcohol.39 

•  The  NIAAA,  in  collaboration  with  the 
American  Academy  of  Pediatrics  (AAP) 
recently  introduced  a  simple  screening  tool 
for  identifying  early  signs  of  risky  alcohol 
use  in  young  people  ages  9-18.  The 
screener  begins  with  two  simple  questions 
assessing  the  child's  own  alcohol  use  and 
that  of  his  or  her  friends.  Depending  on  the 
patient's  age,  positive  responses  to  these 
items  would  be  followed  by  more  in-depth 
questions  assessing  the  level  of  the  patient's 
risk  and  the  provision  of  appropriate  brief 
interventions.40 

•  A  recent  study  found  that  a  single-question 
screening  test  to  identify  other  drug  use  in  a 
diverse  sample  of  adult  primary  care  patients 
was  effective  in  accurately  identifying  other 
drug  use  and  may  be  beneficial  in  helping 
physicians  identify  potential  medication 
interactions  and  associated  risks  of 
prescribing  specific  medications.41 

Single-item  screening  tools  can  help  narrow  the 
patient  population  that  requires  further 
assessment  for  the  identification  of  addiction.42 
However,  most  instruments  focus  on  specific 
substances  rather  than  the  range  of  addictive 
substances  that  pose  a  risk  for  addiction.  The 
National  Institute  on  Drug  Abuse  (NIDA)  has 
begun  to  move  in  the  direction  of  a  more  unified 
look  at  risky  use  and  addiction  with  the 
development  of  a  "quick  screen"  for  use  in 
general  medical  settings.  The  instrument 
actually  contains  four  separate  screens  and  asks 
patients  about  the  frequency  of  their  past-year 
use  of  each  of  the  following  types  of  substances: 
(1)  tobacco,  (2)  alcohol,5  (3)  prescription  drugs 


1  How  many  times  in  the  past  year  have  you  had  5  or 
more  drinks  in  a  day  (for  men)/4  or  more  drinks  in  a 
day  (for  women)? 

*  How  many  times  in  the  past  year  have  you  used  an 
illegal  drug  or  used  a  prescription  medication  for 
nonmedical  reasons? 

§  With  separate  measures  of  risk  for  males  and 
females— the  frequency  of  having  five  or  more  drinks 
in  a  day  for  men  and  four  or  more  drinks  in  a  day  for 
women. 


-67- 


(for  nonmedical  reasons)  and  (4)  illicit  drugs. 
Response  options  for  each,  on  a  five-point  scale, 
range  from  never  to  daily  or  almost  daily.  Used 
online,  the  screening  tool  tallies  the  responses  to 
generate  a  score  indicating  the  patient's  level  of 
risk  for  each  type  of  substance  and  the 
recommended  level  of  intervention.  It  also 
provides  additional  resources  to  help 
practitioners  intervene  appropriately.43 


Implementing  screening  and  brief  intervention 
would  be  a  revolution  in  21st  century  medical 
practice.  It  would  help  reduce  billions  of 
dollars  annually  in  lost  productivity,  injury  and 
social  costs  associated  with  risky  behaviors.  It 
would  also  encourage  those  with  chronic 
conditions  to  get  the  treatment  they  need.  But 
medical  practices  are  unlikely  to  take  action 
without  pressure  from  others  who  would 
benefit.  The  question  is,  when  will  society 
demand  this  change?^ 

-John  C.  Higgins-Biddle,  PhD 
Assistant  Professor  (Retired) 
Community  Medicine  and  Health  Care 
University  of  Connecticut  Health  Center 


Laboratory  Tests 

One  approach  to  screening  is  to  examine 
laboratory  values  of  urine,  hair,  blood,  sweat, 
saliva  or  carbon  monoxide*  to  determine  the 
presence  of  nicotine,45  alcohol46  or  other  drugs.4 
Laboratory  tests  also  can  be  used  to  look  for 
biological  symptoms  of  chronic  substance  use.48 
For  example,  to  assess  heavy  alcohol  use, 
doctors  can  look  for  elevated  levels  of  the  blood 
proteins  gamma-glutamyl  transferase  (GGT)  or 
carbohydrate-deficient  transferrin  (CDT). '  The 
size  of  red  blood  cells  also  increases  with 
prolonged  heavy  alcohol  use.49  The  validity  of 
testing  for  these  markers  as  a  means  of 
identifying  risky  alcohol  use  is  limited  by  the 
fact  that  they  are  not  necessarily  unique  to  risky 
drinkers.50  For  instance,  increased  GGT  also 


*  Carbon  monoxide  breathalyzer  tests  used  to  detect 
smoking. 

'  Heavy  drinkers  are  defined  in  this  context  as 
individuals  who  consume  four  or  more  drinks  per 
day.  CDT  is  less  accurate  at  determining  heavy 
drinking  in  women  and  adolescent  populations. 


can  be  caused  by  nonalcoholic  liver  disease.  At 
the  same  time,  looking  for  biological  markers  is 
more  objective  than  using  a  patient's  self- 
reports,51  as  it  is  not  subject  to  patients'  or 
examiners'  biases. 

Unlike  tests  for  other  diseases  such  as  diabetes 
and  hypertension  which  can  be  diagnosed  using 
blood  sugar  or  blood  pressure  measurements, 
there  is  not  a  conclusive  test  that  physicians  can 
conduct  to  determine  with  certainty  the  presence 
of  the  disease  of  addiction.52  With  few 
exceptions,*  laboratory  tests  for  nicotine,  alcohol 
and  other  drugs  generally  inform  health  care 
providers  of  whether  patients  recently5  have 
been  using  these  substances  rather  than  being 
indicators  of  chronic  use  or  addiction.53 

Individuals,  groups  and  organizations  may  be 
hesitant  to  agree  to  laboratory  tests  for  substance 
use  for  legal,  financial  or  personal  reasons.54 
Widespread  use  of  these  tests  is  costly55  and,  as 
with  any  other  biological  testing,  the  possibility 


1  A  liver  function  test  that  indicates  an  elevated  level 
of  GGT  and  a  complete  blood  count  that  indicates 
that  the  red  blood  cells  have  a  greater  than  normal 
mean  corpuscular  volume  (MCV)  are  evidence  of 
chronic  heavy  alcohol  use. 

§  With  regard  to  smoking,  high  levels  of  nicotine  or 
cotinine  indicate  active  tobacco  use  or  use  of  nicotine 
replacement  therapy  (NRT);  moderate  concentrations 
indicate  a  smoker  who  has  not  had  tobacco  or 
nicotine  for  two  to  three  weeks;  lower  levels  may 
indicate  a  non-smoker  who  has  been  exposed  to 
environmental  tobacco  smoke;  and  very  low  to  non- 
detectible  concentrations  are  found  in  non-smokers 
who  have  not  been  exposed  to  environmental  tobacco 
smoke  or  a  smoker  who  has  not  used  tobacco  or 
nicotine  for  several  weeks.  An  alcohol  test  called  the 
EtG  can  detect  alcohol  up  to  80  hours  after  very 
extensive  drinking  episodes;  however,  in  2006,  the 
Substance  Abuse  and  Mental  Health  Services 
Administration  (SAMHSA)  released  an  advisory 
saying  that  the  EtG  test  was  not  appropriate  for 
assessing  alcohol  use  because  it  is  highly  sensitive 
and  unable  to  distinguish  between  alcohol  absorbed 
into  the  body  from  actual  consumption  and  from 
exposure  to  many  common  commercial  and 
household  products  that  contain  alcohol.  Laboratory 
tests  can  capture  instances  of  other  drug  use  for  days 
or  weeks  after  use,  depending  on  the  drug. 


-68- 


of  errors  such  as  false  positives,  contamination 
or  mislabeling  exists.56 

Given  these  concerns,  biological  tests  may  be 
most  useful  in  verifying  conclusions  drawn  from 
other  forms  of  screening  and  assessment 
instruments57  or  in  specific  circumstances  where 
any  substance  use  is  sanctioned  (e.g.,  use  by 
those  who  are  underage,  pregnant,  have  health 
problems,  in  jobs  that  require  sustained  attention 
and  vigilance  or  by  juvenile  or  criminal 
offenders).58 

Brief  Interventions  and  Treatment 
Referrals 

For  those  who  screen  positive  for  risky  use  of 
addictive  substances  that  does  not  meet  the 
threshold  of  clinical  addiction,  providing  brief 
interventions  is  an  effective,  low-cost  approach 
to  reducing  risky  use. 59 

Brief  interventions  generally  include  feedback 
about  the  extent  and  effects  of  patients' 
substance  use  and  recommendations  for  how 
they  might  change  their  behavior.60  Brief 
interventions  often  involve  motivational 
interviewing  techniques f  and  substance-related 
education;  the  exact  approach  may  differ 
depending  on  the  target  population.61  Brief 
interventions  can  be  conducted  face-to-face, 
over  the  phone  or  via  computerized  feedback  to 
patients.62  They  can  be  performed  by  health 
professionals  after  relatively  limited  training.63 
Providing  brief  interventions  can  save  lives  and 
reduce  a  broad  range  of  negative  health  and 
social  consequences  including  addiction. 


e.g.,  truck  drivers,  air  traffic  controllers,  physicians. 
'  Motivational  interviewing  is  a  patient-centered 
approach  to  counseling.  Counselors  attempt  to 
initiate  behavior  change  through  reflective  listening. 
They  help  patients  resolve  any  ambivalence  toward 
reducing  their  substance  use  through  an  empathetic 
discussion  of  the  discrepancies  between  their  values 
and  self-image  and  their  current  substance  use 
behavior.  Counselors  stress  ideas  of  self-efficacy  and 
optimism  to  their  patients.  (For  a  more  detailed 
discussion,  see  Chapter  V.) 


For  individuals  showing  signs  of  addiction, 
providing  treatment  or  referral  to  specialty  care* 
is  critical  to  managing  the  condition  and 
preventing  further  health  and  social 
consequences.64 

Tobacco 

Brief  interventions  for  smoking  and  other 
tobacco  use  can  be  provided  by  trained  health- 
care practitioners  and  generally  occur  in  clinical 
and  primary-care  settings.65  According  to 
clinical  guidelines,  practitioners  should  provide 
brief  interventions  based  on  the  "Five  A's": 

•  Ask.  The  process  begins  with  inquiries 
about  tobacco  use,  which  should  be  made 
during  every  visit. 

•  Advise.  Individuals  who  smoke  should  be 
advised  in  a  clear,  strong  and  personalized 
manner  to  quit. 

•  Assess.  Practitioners  should  determine 
whether  or  not  a  patient  is  willing  to  attempt 
to  quit. 

•  Assist.  If  the  patient  is  willing  to  attempt  to 
quit,  the  practitioner  should  provide 
assistance  by  helping  patients  create  a  quit 
plan,  providing  counseling  and 
pharmaceutical  treatment  recommendations, 
offering  problem  solving  and  skills  training 
and  distributing  supplementary  educational 
materials.  One  intervention  approach  is 
known  as  the  "Five  R's"  where  a  technique 
is  implemented  to  help  motivate  patients  to 
quit  smoking.66 

•  Arrange.  Schedule  follow-up  contact,  either 
in  person  or  by  phone.67 


1  See  Chapters  V  and  VI. 

-69- 


The  "Five  R's" 

Employing  an  empathetic  counseling  style, 
practitioners  should: 

•  Relevance:  Encourage  patients  to  indicate 
why  quitting  is  personally  relevant. 

•  Risks:  Help  patients  identify  the  acute, 
long-term  and  environmental  risks  they  take 
by  continuing  to  smoke. 

•  Rewards:  Help  point  out  the  rewards  that 
will  come  with  cessation. 

•  Roadblocks:  Ask  patients  to  identify  any 
roadblocks  they  may  face  during  their 
attempt  to  quit  and  suggest  potential 
solutions  for  each. 

•  Repetition:  Repeat  this  process  every  time 
they  see  the  patient. 


Brief  interventions  for  smoking  cessation  should 
include  a  follow-up  visit  scheduled  shortly  after 
a  patient's  quit  date.68 

A  more  simple  approach  that  is  gaining  traction 
is  to  restrict  the  brief  intervention  to  the  first  two 
"A's"— Ask  and  Advise— and  then  refer  the 
patient,  usually  to  a  telephone  quitline  or  a 
smoking  cessation  service,  where  the  other  three 
"A's"  are  performed.69  A  recent  review  of 
research  found  that  compared  to  just  providing 
advice,  physicians  who  offered  assistance  in 
quitting  to  all  patients  who  smoke  regardless  of 
their  stated  willingness  to  quit,  could  prompt  an 
additional  40  percent  to  60  percent  of  smokers  to 

70 

try  quitting. 

There  is  some  evidence  to  suggest  that  shorter 
interventions  for  smoking  cessation  may  be 
more  successful  than  longer  ones,  perhaps 
because  of  the  direct,  instructional  nature  of  the 
brief  intervention.  A  study  of  smokers  with 
addiction  involving  alcohol  enrolled  in  an 
addiction  treatment  program  found  that  35 
percent  of  those  who  received  a  10-minute  brief 
intervention  for  tobacco  use  were  abstinent  a 
month  later  compared  to  only  1 3  percent  of 
those  who  received  a  more  extensive,  50-minute 


In  the  form  of  counseling  or  nicotine  replacement 
therapy  (see  Chapter  V). 


motivational  interview  session. 1  The  brief 
advice  session  directly  told  patients  to  quit 
smoking  and  assisted  participants  in  accessing 
additional  information  or  help  to  reach  that  goal. 
In  contrast,  the  more  extensive  motivational 
interview  focused  on  the  advantages  and 
disadvantages  of  smoking,  imagining  life 
without  smoking,  providing  personalized 
feedback  and  setting  stage-specific  goals.71 

Alcohol  and  Other  Drugs 

Based  on  screening  results,  brief  interventions 
for  alcohol  and  other  drug  use  begin  with 
feedback  about  the  quantity  and  frequency  of  a 
patient's  substance  use,  and  the  potential 
consequences  the  patient  may  face  as  a  result.72 
Brief  interventions  typically  involve  the 
counseling  technique  of  motivational 
interviewing.'1' 73 

Health  care  practitioners  trained  in  providing 
brief  intervention  services  try  to  help  patients 
decide  to  change  their  substance  use  behavior  in 
light  of  the  adverse  medical  and  social 
consequences  of  risky  use  of  addictive 
substances  and  the  many  ways  in  which  it  may 
conflict  with  their  values  and  goals,  and  then 
offer  advice  on  how  patients  may  do  so.74 

The  advice  for  adults5  may  include: 

•  Setting  a  specific  limit  on  consumption; 

•  Learning  to  recognize  the  antecedents  of 
substance  use  and  developing  skills  to  avoid 
use  in  those  situations; 


1  After  six  months,  the  abstinence  rates  of  both 
groups  had  fallen  to  13  percent  and  two  percent, 
respectively. 
*  See  Chapter  V. 

§  Given  the  dangers  of  substance  use  during  the 
vulnerable  period  of  brain  development  that 
continues  into  young  adulthood,  the  advice  for 
adolescents  and  young  adults  who  have  not  reached 
the  legal  ages  for  smoking  or  drinking  alcohol, 
should  focus  less  on  limiting  risky  use  and  more  on 
abstaining  from  use  of  all  addictive  substances. 


-70- 


•  Planning  ahead  to  limit  drinking  and  other 
drug  use; 

•  Pacing  one's  use;  and 

•  Learning  to  cope  with  the  everyday 
problems  that  may  lead  to  substance  use.75 


Helping  patients  understand  how  they  can 
change  their  behavior  and  encouraging  them  to 
be  optimistic  about  their  ability  to  do  so  are 
important  components  of  most  brief 
interventions.77  Interventions  delivered  in  an 
empathetic  counseling  style  are  more  effective 
than  those  that  rely  on  confrontation  or 
coercion.78  While  brief  interventions  can  avert 
the  development  of  a  more  serious  substance  use 
problem,79  individuals  with  the  disease  of 
addiction  require  more  intensive  care  and  should 
be  treated  or  referred  to  specialty  care. 

Effectiveness  of  Screening  and  Brief 
Interventions 

The  combination  of  screening  and  brief 
interventions  has  shown  positive  results  for 
tobacco,80  alcohol,81  illicit  drugs  and  the  misuse 


Sometimes  referred  to  as  SBI. 


of  controlled  prescription  drugs,    across  many 
settings  and  population  groups. f  83 

Several  large-scale  studies  have  explored  the 
effectiveness  of  screening  and  brief 
interventions  in  reducing  the  consumption  of 
addictive  substances  as  well  as  the  serious 
problems  and  costs  that  accompany  such 
behavior,  including  visits  to  emergency 
departments,  hospitalization,  high-risk  injection 
drug  use,  criminal  activity,  psychiatric  stress 
and  depression.84  One  study  found  that  adult 
patients1  receiving  a  brief  intervention  after  a 
positive  screen  by  their  primary  care  physicians 
for  risky  alcohol  use  experienced  20  percent 
fewer  emergency  department  visits  and  37 
percent  fewer  days  of  hospitalization  than 
patients  who  did  not  receive  the  intervention.85 
Participants  who  received  screening  and  brief 
interventions  also  had  significantly  fewer  arrests 
for  alcohol  or  controlled  drug  violations  (two  vs. 
1 1  arrests).86 

A  large-scale  study  conducted  in  a  broad  range 
of  medical  settings  across  six  states  found  that 
22.7  percent  of  the  patients  in  the  study  screened 
positive  for  risky  alcohol  or  other  drug  use  or 
addiction.  Sixteen  percent  of  the  patients  who 
were  screened  received  a  recommendation  for  a 
brief  intervention,  3.2  percent  received  a 
recommendation  for  brief  treatment  and  3.7 
percent  received  a  referral  to  specialty 


'  It  is  difficult  to  compare  the  effectiveness  rates  of 
different  research  trials  and  programs  as  many  of 
them  use  restricted  populations  and  vary  in  the  length 
and  intensity  of  the  intervention.  Despite  these 
methodological  discrepancies,  there  are  strong  data 
showing  the  effectiveness  of  screening  and  brief 
interventions  in  addressing  risky  use  of  addictive 
substances.  Studies  reporting  successful  outcomes 
tend  to  reflect  situations  where  participation  was 
voluntary  and  may  not  reflect  outcomes  in  a 
population  with  mandatory  participation. 
Furthermore,  most  of  these  studies  examine  the  use 
of  screening  and  brief  interventions  in  primary  care 
settings  as  it  pertains  to  alcohol  use  and  not  to  other 
drug  use. 

*  Between  the  ages  of  1 8  to  65  who  visited  a 
physician's  office  for  routine  care. 


"FRAMES": 
Key  Elements  of  a  Brief  Intervention  for 
Reducing  the  Risky  Use  of 
Alcohol  and  Other  Drugs76 

A  frequently -used  brief  intervention  for  the  risky 
use  of  alcohol  and  other  drugs  includes  six  core 
elements  identified  and  verified  through 
empirical  research  that  can  be  summed  up  by  the 
acronym  "FRAMES": 

•  Feedback  regarding  personal  risk  or 
impairment; 

•  Responsibility  for  change; 

•  Advice  to  change; 

•  Menu  of  options  for  reducing  substance  use; 

•  Empathetic  counseling  style;  and 

•  Self-efficacy  in  terms  of  ability  and 
responsibility  to  change. 


-71- 


treatment.   The  study  found  that  brief 
interventions,  brief  treatments  or  referrals  to 
specialty  treatment  for  those  who  screened 
positive  for  risky  alcohol  and/or  illicit  drug  use 
at  baseline  were  associated  with  a  38.6  percent 
reduction  in  rates  of  heavy  alcohol  use  and  a 
67.7  percent  reduction  in  rates  of  illicit  drug  use; 
however,  it  is  important  to  note  that  this  study 
was  not  a  randomized  controlled  trial.87 

Screening  and  brief  intervention  services  also 
have  proven  effective  in  increasing  entry  rates  to 
specialized  addiction  treatment  programs  for 
patients  with  addiction88  and  for  patients  who 
are  required  to  wait  to  enter  standard  treatment 
programs.89 

Tobacco 

When  clinics  and  medical  offices  require 
screening  for  tobacco  use,  tobacco-using 
patients  are  likelier  to  achieve  smoking 
cessation.  This  may  be  because  clinics  and 
medical  offices  that  have  tobacco  screening 
systems  in  place  are  approximately  1.7  times  as 
likely  to  provide  smokers  with  interventions  as 
offices  that  do  not  require  patients  to  undergo 
tobacco  screening.90 

A  systematic  review  of  3 1  studies  examining  the 
effects  of  smoking  interventions  provided  by 
nurses  in  hospital  settings  found  that  the 
smoking  cessation  rate  of  patients  who  received 
brief  interventions  was  1.3  times  the  cessation 


All  patients  in  the  study  were  screened  for  alcohol 
and  other  drug  use;  however,  different  instruments 
were  used  in  each  study  site  and  the  thresholds  for 
being  classified  as  being  a  risky  substance  user  varied 
considerably  among  the  sites.  Those  with  moderate 
risk  substance  use  patterns  received  brief 
interventions  such  as  the  FRAMES  intervention  or 
motivational  interviews;  those  with  heavy  use 
patterns  received  brief  treatment  which  consisted  of 
brief  but  more  intense  interventions  such  as  enhanced 
motivational  interviews  (MI),  motivational 
enhancement  therapy  (MET)  or  cognitive  behavioral 
therapy  (CBT)  (see  Chapter  V  for  an  explanation  of 
these  therapies);  and  those  who  met  clinical  criteria 
for  addiction  were  referred  to  specialty  treatment. 
There  was  no  control  or  comparison  group  in  this 
study. 


rate  of  control  group  patients.      Another  large- 
scale  study  found  that  smokers  who  reported  that 
they  had  received  a  brief  smoking  cessation 
intervention  from  their  primary  care  provided 
were  more  than  three  times  likelier  to  quit 
smoking  than  those  who  did  not  receive  such 
counseling  (34.9  percent  vs.  10.5  percent  among 
patients  without  co-occurring  addiction 
involving  alcohol  or  other  drugs  or  mental  health 
disorders  and  31.3  percent  vs.  6.0  percent  among 
those  with  such  co-occurring  conditions).92 

Alcohol 

Screening  and  brief  interventions  for  risky 
alcohol  use  have  demonstrated  efficacy  in 
primary  care  and  emergency/trauma  settings.93 
One  study,  conducted  in  a  primary  care  setting 
with  patients  who  screened  positive  for  risky 
alcohol  use,  found  a  greater  decline  in  the 
number  of  people  who  reported  binge  drinking5 
among  those  receiving  a  brief  intervention  (from 
85.0  percent  at  baseline  to  61.5  percent  three 
years  after  the  first  intervention)  compared  to 
those  in  the  control  group  (from  86.9  percent  at 
baseline  to  70.7  percent  three  years  after  the  first 
intervention).    Likewise,  there  was  a  greater 
decline  in  the  number  of  people  who  reported 
heavy  drinking' '  among  those  receiving  the  brief 
intervention  (from  46.7  percent  at  baseline  to 
23.2  percent  three  years  after  the  first 
intervention)  compared  to  those  in  the  control 


'  The  effects  of  the  interventions  appear  to  be 
strongest  among  cardiac  rehabilitation  patients. 
*  As  indicated  by  a  positive  response  to  the  question, 
In  the  past  12  months,  did  any  of  the  general  medical 
providers  talk  to  you  about  quitting  or  avoiding 
smoking? 

§  Defined  in  this  study  as  consuming  more  than  five 
drinks  on  one  occasion  during  the  previous  30  days. 

The  brief  intervention  included  a  health 
information  booklet,  two  face-to-face,  15-minute 
intervention  sessions  with  a  physician  spaced  one 
month  apart  and  two  follow-up  calls  from  nurses 
during  the  weeks  following  their  interventions;  the 
control  group  only  received  the  information  booklet. 
Patients  were  randomly  assigned  to  one  of  these  two 
conditions. 

^  Consuming  more  than  20  drinks  during  the  past 
week  for  men  and  more  than  13  drinks  during  the 
past  week  for  women. 


-72- 


group  (from  49.2  percent  at  baseline  to  34.6 
percent  three  years  after  the  first  intervention). 
The  intervention  participants  also  experienced 
55  percent  fewer  nonfatal  motor  vehicle  crashes 
and  46  percent  fewer  arrests.94  Another  study 
found  that  a  30-minute  brief  intervention  was 
associated  with  significantly  fewer  at-risk 
patients  being  arrested  for  driving  under  the 
influence  of  alcohol  during  the  next  three  years 
(1 1.3  percent  of  brief  intervention  patients  had  a 
DUI  arrest  vs.  21.9  percent  of  control  group 
patients).95 

A  systematic  review  of  emergency  department- 
based  screening  and  brief  intervention  programs 
found  that  82  percent  of  the  studies  included  in 
the  review  demonstrated  a  positive  effect. '  96 
Even  in  non-emergency  cases  and  cases 
seemingly  unrelated  to  substance  use  (e.g., 
general  surgery  and  anesthesia  consults), 
routinely  screening  all  pre-surgical  patients  for 
risky  use  and  addiction  can  prevent 
complications  from  surgery,  and  brief 
interventions  or  referral  to  treatment  can  prevent 
the  presenting  condition  from  worsening.97 
Brief  interventions  conducted  in  trauma  centers 
for  patients  who  engage  in  risky  alcohol  use 
have  been  associated  with  a  47  percent  reduction 
in  re-injuries  requiring  emergency  department  or 
trauma  center  admission  and  a  48  percent 
reduction  in  re-injuries  requiring  hospital 
admission.98  Brief  interventions  with  follow-up 
are  more  effective  than  single-contact 

qq  .  .  . 

interventions:    a  review  comparing  multi- 
session  and  single-session  brief  alcohol 
interventions  found  that  those  who  received 
multi-session  brief  interventions  reported  a  13  to 
34  percent  greater  reduction  in  the  average 
number  of  drinks  per  week  after  six  to  12 


months  than  those  receiving  single-session  brief 
interventions.*  100 

Other  Drugs 

Although  the  research  on  screening  and  brief 
interventions  for  other  drug  use  is  quite  limited 
and  therefore  data  supporting  these  services  is 
scarcer  than  in  relation  to  tobacco  and  risky 
alcohol  use,101  the  available  research  suggests 
that  screening  and  brief  interventions  can  reduce 
other  drug  use  among  patients  in  primary  care 
facilities,  emergency  departments,  trauma 
centers  and  other  hospital  units.102  In  one  study 
conducted  at  six  health  care  sites  across  the 
country,  patients  who  screened  positive  for  drug 
use  (other  than  tobacco  or  alcohol)  received 
screening  and  brief  interventions,  brief  treatment 
or  referrals  to  treatment  based  on  the  severity  of 
their  drug  use.  Six  months  after  receiving  these 
interventions,  the  percentage  of  patients 
reporting  past  month  marijuana,  cocaine, 
methamphetamine,  heroin  or  other  drug  use- 
including  the  misuse  of  prescription  sedatives 
and  opioids  as  well  as  hallucinogens  and 
inhalants-decreased  significantly.103  However, 
this  study  did  not  contain  a  control  condition  so 
the  extent  to  which  substance  use  would  have 
decreased  without  these  interventions  cannot  be 
determined.  (Figure  4.A) 

Patients  in  the  study  reported  significant 
increases  in  health  status  (from  fair  to  good)  and 
employment  (from  31.3  percent  to  36.1  percent) 
at  the  six-month  follow-up  as  well.  There  also 
were  significant  decreases  in  the  percentage  of 
patients  reporting  past-month  emotional 
problems  (from  25.6  percent  to  17.6  percent), 
arrests  (from  12.2  percent  to  4.4  percent)  and 
homelessness  (from  1 1.8  percent  to  6.4 
percent).104 


Specifically,  those  who  have  a  BAC  >  80  mg/dL  or 
a  score  >  8  on  the  AUDIT  screening  instrument. 
*  Ninety  percent  showed  a  decrease  in  alcohol 
consumption,  13  percent  showed  a  decrease  in 
emergency  department  visits  and  hospitalizations,  13 
percent  showed  a  decrease  in  negative  social 
consequences  and  13  percent  showed  an  increase  in 
referrals  for  follow-up  and/or  treatment. 


1  Ranges  rather  than  single  values  are  cited  because 
the  figures  come  from  a  meta-analysis  comparing 
results  from  multiple  studies. 


-73- 


Figure  4. A 

Pre-  and  Post-Past  Month  Use  of  Specific  Drugs  among 
Patients*  Exposed  to  Screening  and  Interventions 


65 


37 


21 


ft 


12 


•  Baseline 

1 6  Month  Follow  Up 
18 


10 

3 

5 

Marijuana 


Cocaine 


Methamphetamine 


Heroin 


Other  Drugs 


*  Who  report  any  illicit  drug  use  at  baseline. 

Source:  Madras,  B.K.,  Compton,  W.M.,  Avula,  D.,  Stegbauer,  T,  Stein,  J.B., 
Clark,  H.W.  (2009). 


Another  study  found  that  a  screening  and  brief 
intervention  program*  for  heroin  and  cocaine 
users  implemented  during  a  routine  medical  visit 
was  related  to  greater  abstinence  among 
intervention  versus  control  participants  from 
cocaine  use  (22.3  percent  vs.  16.9  percent)  and 
heroin  use  (40.2  percent  vs.  30.6  percent)  six 
months  following  the  intervention. 


105 


Brief  interventions  also  can  reduce  regular 
amphetamine  use.  Six  months  after  screening 
positive  for  amphetamine  use,  individuals  who 
received  brief  interventions f  were  significantly 
likelier  to  be  abstinent  than  users  who  received 
only  self-help  booklets.  Amphetamine  users 
who  received  brief  interventions  also  showed 
decreased  psychiatric  distress  scores  and 
depression  levels.106 


Consisting  of  toxicological  and  questionnaire 
screening  during  routine  care  at  an  inner-city 
teaching  hospital,  as  well  as  brief  motivational 
interviews,  active  referrals,  a  list  of  treatment 
providers  and  a  follow-up  booster  phone  call. 
'  In  this  study,  each  participant  had  four  45-  to  60- 
minute  individual  therapy  sessions  guided  by  a 
therapist  manual  and  a  self-help  booklet.  The 
sessions  included  role-play  and  take-home  exercises, 
concentrating  on  coping  strategies  and  relapse 
prevention.  The  first  session  focused  on  increasing 
motivation  to  reduce  drug  use,  the  second  on 
reducing  cravings  through  muscle  relaxation  and  self 
talk,  the  third  on  controlling  thoughts  about  drug  use 
and  the  fourth  on  coping  with  lapses  and  developing 
skills  to  use  in  high-risk  situations. 


Implementing 
Screening  and 
Brief 

Interventions  in 
Health  Care  and 
Other  Settings 

While  screening  and 
brief  interventions  can 
be  provided  in  a  broad 
range  of  venues,107 
health  care  settings  may 
be  the  most  effective. 
Physicians  and  other 
health  care  providers,  including  dental 
professionals,  nurses  and  pharmacists,  typically 
are  a  consistent,  trusted  and  influential  presence 
in  the  lives  of  children  and  adults  and  their 
professional  position  grants  them  the  authority 
and  credibility  to  deliver  effective,  evidence- 
based  interventions  to  patients  at  risk  for 
complications  related  to  their  substance  use, 
including  addiction.  Part  of  the  success  of 
incorporating  these  services  for  risky  use  of 
addictive  substances  into  standard  medical 
practice  is  that  people  tend  to  be  more  receptive 
to  health  messages  once  they  are  in  a  health  care 
setting.  Patients  view  additional  screening, 
information,  brief  intervention  or  referral  to 
treatment  as  part  of  the  health  care  they  sought 
initially.108  The  use  of  technology  to  assist  in 
the  completion  of  screening  and  brief 
interventions  holds  promise  for  helping  to 
integrate  these  practices  into  routine  health  care 
delivery.109 

Primary  Care 

About  80  percent  of  Americans4  visited  at  least 
one  physician  or  other  health  care  professional 
in  the  past  year,110  and  the  American  Society  of 
Addiction  Medicine  (ASAM)  estimates  that 
more  than  two-thirds  of  people  with  addiction 
are  in  contact  with  a  primary  or  emergency  care 
physician  about  twice  a  year. 1 1 1  Integrating 
screening  and  brief  interventions  into  routine 
medical  check-ups  can  be  an  effective  way  of 


Ages  1 8  and  older. 


-74- 


identifying  smoking,  risky  drinking  and  other 
drug  use  before  negative  consequences  occur, 
including  the  development  of  addiction.112 


Although  the  most  promising  research  findings 
regarding  the  benefits  of  implementing  these 
services  in  health  care  and  other  settings  have 
been  found  in  primary  care  settings,  clinical 
trials  are  lacking  in  this  area.114  Given  the 
strong  scientific  evidence  to  date  supporting  the 
use  of  screening  and  brief  interventions, 
particularly  for  smoking  and  risky  alcohol  use, 
several  national  medical  societies  already  have 
endorsed  this  approach,  including: 

•  The  American  Society  of  Addiction 
Medicine  (ASAM)  has  identified  screening 
and  brief  interventions  as  an  effective 
method  for  catching  substance-related 
problems  early  and  preventing  the 
development  of  addiction;  ASAM 
encourages  medical  and  insurance 
professionals  to  redesign  their  primary  care 
and  funding  practices  to  accommodate  these 
programs.115 

•  The  American  Academy  of  Family 
Physicians  recommends  that  adults, 
including  pregnant  women,  be  screened  for 
tobacco  use  and  provided  with  cessation 
interventions  or  brief  counseling  and  that 
screening  and  brief  interventions  for  alcohol 
use  be  used  in  health  care  settings  as  well.116 


•  The  American  College  of  Obstetricians  and 
Gynecologists'  Committee  on  Ethics 
declared  that  obstetrician-gynecologists 
have  an  ethical  obligation  to  conduct 
universal  screening,  brief  intervention  and 
referral  to  treatment  for  their  patients.117 

•  The  American  Dental  Association  advises 
dentists  to  address  the  issue  of  risky  use  and 
addiction  with  patients  and  refer  them  to 
appropriate  addiction  treatment  if  needed.118 

Even  the  United  States  Preventive  Services  Task 
Force  (USPSTF),  which  is  constrained  by 
available  medical  evidence,  has  recommended 
screening  and  brief  intervention  for  risky  alcohol 
use  for  all  adults  in  primary  care  settings,* 119 
and  that  all  adults,  including  pregnant  women, 
be  screened  for  tobacco  use  and  receive 
appropriate  cessation  counseling/  120  And,  the 
National  Quality  Forum  has  endorsed  screening 
and  brief  interventions  for  tobacco  and  alcohol 
use  in  general  health  and  mental  health-care 

1  21 

settings. 

Adolescent  Health  Care.  Screening  the 
adolescent  population  for  substance  use  may  be 
the  single  most  effective  preventive  step  that  can 
be  taken  to  address  the  problem  of  risky  use  and 


The  USPSTF  recommends  this  service  with  a  B 
rating,  indicating  that  the  net  benefits  of  the 
intervention  outweigh  any  potential  harms. 
'  The  USPSTF  recommends  this  service  with  an  A 
rating,  indicating  that  the  net  benefits  of  the 
intervention  substantially  outweigh  the  harms;  for 
pregnant  women,  the  Task  Force  recommends  that 
the  counseling  services  be  tailored  to  pregnancy.  As 
a  result  of  limited  research  on  the  topic,  the  USPSTF 
concluded  that  there  currently  is  insufficient  clinical 
evidence  to  determine  the  balance  of  benefits  and 
harms  of  routine  (asymptomatic)  screening  or 
interventions  for  tobacco  or  alcohol  use  among 
adolescents  or  for  screening  individuals  for  illicit 
drug  use  in  primary  care  practice  settings.  A  recent 
report  by  the  USPSTF,  however,  identified  1 1  high- 
priority  areas  in  preventive  medicine  that  have 
critical  evidence  gaps  that,  if  addressed  through 
targeted  research,  are  likely  to  result  in 
recommendations  for  practice.  Among  these  1 1 
high-priority  areas  are  screening  and  providing 
counseling  for  adolescent  alcohol  use  and  screening 
all  individuals  for  illicit  drug  use. 


The  2010  National  Drug  Control 
Strategy  Recommends: 

•  Increasing  health  care  providers' 
knowledge  and  use  of  screening  and  brief 
intervention  techniques  through  enhanced 
medical  and  nursing  school  educational 
programs; 

•  Increasing  screening  and  early  intervention 
for  substance  use  in  all  health  care  settings; 
and 

•  Increased  reimbursement  for  screening  and 
brief  interventions  in  primary  care.113 


-75- 


addiction  in  this  country  since  the  consequences 
of  risky  use  of  addictive  substances  among 
adolescents  are  so  profound  and  individuals  with 
addiction  typically  began  engaging  in  risky  use 
in  adolescence.122 


The  primary  care  office  is  a  key  setting  for 
adolescent  screening  and  brief  intervention 
related  to  substance  use;  using  computer 
technology  to  achieve  these  ends  meets  the  needs 
of  both  patients  and  physicians  by  making  the 
process  more  efficient  and  easier  for  physicians, 
producing  more  honest  responses  from  patients, 
and  increasing  both  providers'  and  patients' 
satisfaction  with  the  encounter. 126 

--John  R.  Knight,  MD 
Director, 

Center  for  Adolescent  Substance  Abuse  Research 
Associate  Professor  of  Pediatrics, 
Harvard  Medical  School 
Senior  Associate  in  Medicine, 
Associate  in  Psychiatry, 
Children's  Hospital  Boston 


>  Be  knowledgeable  about  addiction  and 
skilled  in  recognizing  the  risk  factors  for 
substance  use  among  young  people; 

>  Screen  all  patients  for  substance  use  at 
annual  medical  examinations  and,  if 
possible,  at  other  medical  visits  as  well 
using  screening  methods  that  are 
validated,  nonjudgmental  and  that 
protect  confidentiality; 

>  Provide  brief  interventions  and  refer 
patients,  when  necessary,  to  treatment  or 
specialty  care; 

>  Consider  and  address  co-occurring 
disorders;  and 

>  Promote  substance  use  prevention 
programs  and  media  responsibility  with 
regard  to  depictions  of  substance  use.127 

Emergency  and  Trauma  Care 


The  U.S.  Public  Health  Service's  clinical 
practice  guideline  for  tobacco  use  and 
dependence  recommends  that  clinicians  ask 
adolescent  patients  about  their  tobacco  use  and 
provide  them  with  brief  interventions  to  aid  in 
quitting.123 

Professional  medical  associations  such  as  the 
American  Medical  Association  (AMA)  and  the 
American  Academy  of  Pediatrics  (AAP)  support 
screening  adolescent  patients  for  substance  use, 
and  promote  the  use  of  screening  and  brief 
intervention  techniques  among  their 

124 

constituents: 

•  The  AMA' s  Guidelines  for  Adolescent 
Preventive  Services  recommend  that 
physicians  ask  all  adolescents  annually 
about  their  use  of  tobacco,  alcohol  and  other 
drugs,  including  over-the-counter  drugs, 
controlled  prescription  drugs  and  anabolic 
steroids.125 

•  The  American  Academy  of  Pediatrics 
(AAP)  encourages  pediatricians  to: 


Emergency  Departments  (EDs)  and  trauma 
centers  are  particularly  critical  venues  for 
screening  and  brief  intervention  since  so  many 
emergency  and  trauma  cases  involve  risky 
substance  use.  One  study  found  that  up  to  3 1 
percent  of  all  patients  treated  in  hospital  EDs 
who  were  screened  for  risky  alcohol  usef  had  a 
positive  result.  +  128  Many  trauma  patients  meet 
criteria  for  addiction;  a  study  of  seriously  injured 
trauma  patients  shows  that  24.1  percent  of  them 
met  diagnostic  criteria  for  alcohol  dependence 
and  17.7  percent  for  other  drug  dependence}29 
Further,  substance-using  individuals  frequently 
rely  on  EDs  for  much  of  their  health-care 


Fifty  percent  of  severely  injured  trauma  patients  and 
22  percent  of  minor  trauma  patients  receive  their 
injuries  under  the  influence  of  alcohol. 
'  Based  on  the  CAGE  questionnaire. 
*  Fhis  most  likely  is  a  conservative  estimate  since 
many  EDs  do  not  screen  for  alcohol  or  other  drug  use 
because  of  insurance  laws  (i.e.,  the  Uniform  Accident 
and  Sickness  Policy  Provision  Law-UPPL)  restricting 
payment  if  the  reason  for  admission  was  substance 
related. 


-76- 


EDs  and  trauma  centers  are  ideal  settings  for  the 
"teachable  moment"  that  is  thought  to  be  one  of 
the  key  components  of  the  positive  impact  of  a 
brief  intervention.131  Most  individuals  who 
experience  substance-related  accidents  and 
injuries  do  not  meet  clinical  criteria  for 
addiction132  but  are  excellent  candidates  for  brief 
interventions.  One  study  of  young  adults 
admitted  to  a  hospital  emergency  department 
found  that  those  who  were  alcohol-involved 
and  who  received  a  brief  motivational 
intervention  followed  by  two  telephone  booster 
sessions  showed  greater  reductions  in  alcohol 
use  than  those  who  just  received  one  to  three 
minutes  of  feedback,  in  which  they  were 
provided  information  about  how  much  they 
drink,  what  happens  when  they  drink  and  how 
their  alcohol  intake  compares  to  their  peers  (a 
reduction  of  up  to  53  percent  vs.  18  percent).133 


ED  and  trauma  physicians  were  some  of  the  first 
to  recommend  the  adoption  of  screening  and 
brief  interventions;134  their  focus  to  date  has 
been  on  excessive  alcohol  use  which  is  the 
leading  risk  factor  for  injury:135 

•  The  American  College  of  Emergency 
Physicians  recommends  screening  and  brief 
interventions  for  alcohol  use.136 

•  The  American  College  of  Surgeons 
Committee  on  Trauma  requires  that  Level  I 
and  Level  II  trauma  centers  have  a 
mechanism  in  place  to  identify  patients  who 


Screened  positive  for  alcohol  use,  reported  drinking 
in  the  six  hours  before  their  accident  or  had  a  history 
of  risky  drinking  (as  determined  by  their  AUDIT 
score). 


engage  in  risky  alcohol  use  and  Level  I 
Centers  must  have  a  mechanism  in  place  to 
intervene  with  these  patients.1"  137 

An  important  point  of  access  to  the  health  care 
system  for  adolescents  is  through  the  ED; 
approximately  12.7  percent  of  substance-related 
ED  visits  are  made  by  individuals  ages  12  to  20 
years  old  (5.7  percent  by  those  ages  12  to  17  and 
7.0  percent  by  those  ages  18  to  20). 138 
Interventions  conducted  in  the  ED  may  reach 
adolescents  who  do  not  attend  school  regularly 
or  who  do  not  have  a  primary  care  physician.139 

Health  Care  for  Pregnant  Women* 

Given  the  considerable  impact  of  substance  use 
on  reproductive  health  and  pregnancy,  women 
(especially  those  who  are  pregnant  or  of 
reproductive  age)  are  an  ideal  target  for 
screening  and  brief  intervention  services.141 
Because  there  is  no  universally  safe  level  of 
substance  use  during  pregnancy,  any  use  should 
be  screened  for  and  addressed.  The  American 
College  of  Obstetricians  and  Gynecologists 
recommends  that  because  of  these  risks,  all 
women— regardless  of  present  pregnancy  status- 
should  be  screened  for  alcohol  use  at  least  yearly 
and  provided  with  intervention  and  referral 
services  if  necessary.142 

One  study  found  that  pregnant  smokers  who 
received  brief  counseling  and  behavioral 
interventions  in  a  public  maternity  hospital  had  a 
higher  rate  of  smoking  abstinence  (33.3  percent) 
than  pregnant  smokers  who  received  usual  care 
(8.3  percent).143  Another  study  found  that 
pregnant  smokers  in  community  health  centers 
who  received  brief  interventions  were  more 
likely  to  be  abstinent  by  the  end  of  their 
pregnancy  than  women  receiving  usual  prenatal 
care  (past-month  abstinence  rate  of  26  percent 
vs.  12  percent).  However,  in  this  study,  the 
higher  rates  of  smoking  abstinence  following  a 


1  The  focus  in  this  area  primarily  has  been  on  alcohol 
rather  than  tobacco  or  other  drugs. 
*  Research  on  screening  and  brief  interventions  for 
pregnant  women  focuses  primarily  on  tobacco  and 
alcohol  use.  No  studies  of  the  use  of  such  services  in 
pregnant  women  who  use  other  drugs  were  found. 


Research  [related  to  screening  and  brief 
intervention]  began  in  the  ED.  The  earliest 
study— conducted  in  1957— was  a  controlled  trial 
with  200  dependent  drinkers  at  Massachusetts 
General  Hospital.  Patients  who  had  a 
nonjudgmental,  respectful  conversation  inviting 
them  to  attend  an  outpatient  program  were  more 
likely  than  other  patients  to  complete  one 
appointment  (65.0  percent  vs.  5.4  percent)  and 
five  appointments  (42.0  percent  vs.  1.1 
percent).140 


-77- 


brief  intervention  disappeared  at  three  and  six- 
month  post-partum  follow-ups,144  indicating  a 
need  for  more  intensive  treatment  services. 

Screening  and  brief  interventions  in  prenatal 
care  settings  have  been  found  to  reduce  alcohol 
use  significantly,145  as  well  as  the  chances  of 
low  birth-weight  deliveries.146  Brief 
interventions  for  alcohol  use  among  pregnant 
women  are  effective  even  when  provided  in  a 
community  setting  by  non-medical 
professionals.147  Programs  that  include  spouses 
and  partners  are  particularly  effective.148 

Mental  Health  Care 

Despite  the  high  rate  of  co-occurring  addiction 
and  mental  health  disorders,149  screening  and 
brief  interventions  for  risky  substance  use  are 
not  common  practice  in  mental  health  settings 
and  are  not  standard  practice  in  the  field  of 
psychiatry.150 

There  are  effective  tools  for  screening  patients 
with  mental  health  conditions  in  mental  health 
settings  for  risky  use  of  addictive  substances151 
and  there  is  evidence  that  interventions  can  be 
effective  in  addressing  such  use  among  those 
with  psychiatric  conditions.152  For  example,  a 
study  evaluating  the  effectiveness  of  a  screening 
and  brief  intervention  program  in  a  primary 
health  and  mental  health  care  setting  at  a 
university  found  that  six  weeks  after  receiving 
the  intervention,  participants  decreased  their 
alcohol  use.* 153 

Dental  Care 

Dental  professionals  can  play  a  unique  role  in 
detecting  substance  use  among  their  patients, 
providing  brief  interventions  and  referring 
patients  to  treatment.154  Risky  use  and  addiction 
have  a  significant  impact  on  multiple 
components  of  dentistry  including  patients'  oral 


*  Including  the  average  number  of  drinks  consumed 
per  week  over  the  past  30  days,  the  highest  number  of 
drinks  consumed  on  one  occasion  in  the  past  30  days 
and  the  number  of  times  in  the  preceding  two  weeks 
participants  had  consumed  five  or  more  drinks  on  one 
occasion. 


health155  and  the  safety  of  common  treatments 
and  interventions  including  the  prescription  of 
controlled  medications  such  as  opioid  pain 
relievers.156  The  fact  that  dental  health 
maintenance  and  treatment  require  routine  and 
often  repeated  visits  makes  dental  professionals 
a  consistent  and  potentially  influential  presence 
in  the  lives  of  people  who  engage  in  risky  use  of 
addictive  substances.157  Dental  patients  are 
receptive  to  their  dentists'  involvement  in  the 
prevention  and  treatment  of  risky  use  and 
addiction.  A  2005  survey  of  patients  visiting  an 
emergency  dental  clinic  found  that  80  percent 
believed  dentists  should  ask  their  patients  how 
much  alcohol  they  drink;  90  percent  believed 
that  dentists  should  warn  patients  to  drink  less 
or  quit  if  it  is  affecting  their  oral  health.158 

Pharmacies 

The  responsibilities  of  pharmacists  with  regard 
to  the  prevention  and  early  intervention  of  risky 
use  and  addiction  extend  to  administering 
prescription  medications;  pharmacists  are  the 
best  source  of  information  regarding  the  safe  and 
effective  use  of  medications  and  the  adverse 
effects  that  arise  from  their  misuse.  They  also 
can  be  instrumental  in  controlling  the  diversion 
of  prescription  medications  for  misuse  by 
monitoring  the  number  of  prescriptions  filled  by 
a  patient,  looking  for  false  or  altered  prescription 
forms159  and  recognizing  when  a  patient  is 
"doctor  shopping"'  or  in  need  of  treatment.160 

High  School,  College  and  University 
Settings 

Screening  and  brief  intervention  programs 
reduce  risky  use  of  addictive  substances  among 
students  by  changing  their  attitudes,  beliefs  and 
expectations  regarding  tobacco,  alcohol  and 
other  drug  use.161 

School  health  programs,  in  collaboration  with 
primary  care  providers,  are  important 
opportunities  for  screening  adolescents  and 
young  adults  for  substance  use,  primarily 


1  The  practice  of  patients  visiting  various  health  care 
providers  to  obtain  multiple  prescriptions  for  the 
drugs  they  misuse. 


-78- 


because  young  people  spend  a  majority  of  their 
time  in  school.  Few  schools,  however,  take 
advantage  of  this  opportunity.162  A  CASA 
Columbia  survey  of  school  personnel,  conducted 
for  its  2011  report,  Adolescent  Substance  Use: 
America 's  #1  Public  Health  Problem,  found  that 
only  7.4  percent  reported  that  their  schools 
screen  all  students  for  signs  of  risky  alcohol  or 
other  drug  use;  9.0  percent  of  high  school 
teachers  reported  that  their  schools  screen 
particular  groups  of  high-risk  students  for  signs 
of  risky  alcohol  or  other  drug  use.163 

The  college  setting  also  is  ideal  for  intervening 
with  young  people  at  risk  via  screening  and  brief 
interventions  because  of  the  high  rates  of 
substance  use  in  the  college  population;  an 
estimated  67.2  percent  are  risky  users  or  have 
addiction.'  169  To  date,  the  majority  of  the 
screening-  and  intervention-related  research 
among  college  students  has  focused  on  alcohol, 
most  likely  because  alcohol  typically  is  the 
substance  most  likely  to  be  used  by  college 
students.170  Screening  and  brief  interventions 
have  proven  successful  in  reducing  risky  alcohol 
use  and  its  consequences  in  this  population.171 
The  Department  of  Education  recommends  the 
implementation  of  screening  and  brief 
intervention  programs  in  all  college  health 

1  7? 

centers. 


Brief  Alcohol  Screening  and  Intervention 
of  College  Students  (BASICS)  Program 

The  BASICS  program  targets  risky  drinkers 
(defined  as  those  who  drink  heavily  and  are  at 
risk  for  or  already  have  experienced  problems 
related  to  alcohol  use)  between  the  ages  of  18 
and  25. 164  Students  are  identified  for 
participation  in  the  programs  through  screening 
or  through  referral  from  medical,  housing  or 
disciplinary  services. 165  The  program  consists  of 
two  one -hour  interviews  and  a  brief  online 
assessment  survey  about  drinking  habits  and 
history,  as  well  as  beliefs  and  attitudes,  while 
giving  instructions  for  monitoring  one's  own 
drinking  between  interviews.  In  the  second 
interview,  students  receive  personalized  face-to- 
face  feedback  about  their  alcohol  use  compared 
with  peer  norms,  consequences  of  and  risk 
factors  for  drinking  and  strategies  for  reducing 
alcohol  use  and  related  problems. 166  The 
BASICS  program  has  proven  to  be  effective  and 
cost-effective.167  In  one  study,  students  who 
received  the  BASICS  intervention  as  college 
freshmen  were  more  likely  than  risky  drinkers 
who  did  not  participate  in  the  intervention  to 
have  reduced  their  alcohol  consumption  four 
years  later  (67  percent  vs.  55  percent).168 


Justice  Settings 

Juvenile  justice  programs  and  facilities  are  ideal 
venues  for  screening  and  brief  interventions; 
CASA  Columbia's  2004  report,  Criminal 
Neglect  Substance  Abuse,  Juvenile  Justice  and 
The  Children  Left  Behind,  found  that  four  of 
every  five  children  and  adolescents  in  the 
juvenile  justice  system  are  substance 
involved.*  173  Unfortunately,  jurisdictions 
typically  do  not  provide  adequate  screening  or 
brief  intervention  services174  even  though  there 
are  several  screening  tools  that  have  been 
validated  for  use  with  juvenile  offenders.175 


Of  enrolled  college  students,  ages  18-22. 
1  43.9  percent  are  risky  users  but  do  not  have 
addiction  and  23.3  percent  have  addiction,  i.e.,  meet 
clinical  diagnostic  criteria  for  past  month  nicotine 
dependence  and/or  past  year  alcohol  and/or  other 
drug  abuse  or  dependence. 


x  Under  the  influence  of  alcohol  or  other  drugs  while 
committing  their  crime,  test  positive  for  drugs,  are 
arrested  for  committing  an  alcohol  or  other  drug 
offense,  admit  to  having  a  substance  use  problem  or 
share  some  combination  of  these  characteristics. 


-79- 


One  national  study  of  juvenile  residential 
facilities  found  that  1 5  percent  of  the  facilities 
that  reported  information  about  evaluating 
residents  for  substance-related  issues  indicated 
that  they  did  not  screen  at  all,  20  percent 
reported  that  they  screened  some  youth  and  64 
percent  reported  that  they  screened  all  youth;  4 1 
percent  reported  using  a  standardized  screening 
instrument.  7   Even  those  facilities  that  screen 
youth  and  use  a  standardized  screening 
instrument  do  not  necessarily  provide 
appropriate  interventions  or  treatment  based  on 
screening  findings.177 

The  criminal  justice  system  includes  even  higher 
concentrations  of  individuals  whose  crimes  are 
linked  to  their  use  of  alcohol  and/or  other  drugs. 
CASA  Columbia's  2010  report  on  substance  use 
in  this  population,  Behind  Bars  II:  Substance 
Abuse  and  America 's  Prison  Population,  found 
that  84.8  percent  of  inmates  in  America  are 
substance  involved.1  178  Screening  can  be  used 
to  identify  those  in  need  of  intervention  and  to 
make  appropriate  referrals  to  treatment,  which 
ultimately  can  help  to  reduce  crime  and  prison 
overcrowding  and  save  taxpayer  money.179 

Despite  abundant  evidence  of  the  efficacy  of 
screening  and  brief  interventions,180 
standardized  screening  and  interventions  are  not 
implemented  regularly  injustice  settings.181 
Although  inmates  are  guaranteed  the  right  to 
medical  care,182  they  routinely  are  denied  access 
to  appropriate  screening,  intervention  and 
treatment  services  for  the  disease  of  addiction.183 

The  Workplace 

The  majority  of  people  ages  18  and  older  who 
meet  clinical  criteria  for  addiction  (63.8  percent) 


Of  the  2,658  facilities  in  the  final  sample,  2,128 
reported  information  about  screening. 
1  Substance-involved  inmates  are  those  who  either 
had  a  history  of  using  illicit  drugs  regularly;  met 
clinical  criteria  for  addiction;  were  under  the 
influence  of  alcohol  or  other  drugs  when  they 
committed  their  crime;  had  a  history  of  alcohol 
treatment;  were  incarcerated  for  a  drug  law  violation; 
committed  their  offense  to  get  money  to  buy  drugs; 
were  incarcerated  for  an  alcohol  law  violation;  or  had 
some  combination  of  these  characteristics. 


or  who  engage  in  risky  use  but  do  not  have 
addiction  (73.0  percent)  are  employed  full  or 
part  time;184  individuals  who  engage  in  risky 
substance  use  or  are  addicted  have  higher  rates 
of  absenteeism,  decreased  work  productivity  and 
higher  health  care  costs.185 

If  approached  as  a  health  issue,  the  workplace  is 
an  ideal  venue  for  offering  confidential 
screening,  brief  interventions  and  treatment 
referrals.  Workplaces  increasingly  rely  on 
Employee  Assistance  Programs  (EAPs)186— 
confidential  counseling  programs  for  employees 
that  offer  assistance  with  health  or  other 
problems  that  can  adversely  affect  job 
performance.187  One  recent  survey  of  human 
resource  professionals  found  that  60  percent 
reported  that  their  organizations  offered 
employee  wellness  programs  and  42  percent  had 
health  screening  programs.188  Only  recently, 
however,  have  there  been  attempts  to  utilize 
EAPs  and  similar  workplace  programs  to 
provide  screening  and  brief  intervention  services 
to  employees.189 

Researchers  have  demonstrated  that  providing 
these  services  to  employees  who  contact  an  EAP 
program  for  assistance  can  be  effective  at 
identifying  risky  use  and  addiction.190  Several 
pilot  studies3-  have  demonstrated  the 
effectiveness  of  identifying  risky  drinking5 
among  employees  via  EAP  services  and  of 
having  those  who  were  identified  agree  to 
follow-up  counseling.191  According  to  a 
national  employer  survey,  however,  only  29 
percent  of  employers  offer  screening  to  their 
employees    for  risky  alcohol  use  and  60  percent 
of  that  group  provide  brief  interventions.192 
Comparable  data  on  the  proportion  of  employers 
that  screen  or  provide  interventions  for 
employees  who  smoke  or  use  other  drugs  are  not 
available. 


J  Conducted  in  partnership  with  Aetna  and 

OptumHealth. 

§  Using  the  AUDIT. 

**  Of  the  employers  that  provide  screening,  most 
reported  using  the  EAP,  human  resources, 
occupational  health  and  safety  and  educational 
outreach  programs  to  conduct  the  screening. 


-80- 


Unfortunately,  much  workplace  screening  takes 
the  form  of  drug  testing  and  is  used  for 
compliance  purposes.  In  this  light,  it  frequently 
is  viewed  as  infringing  on  workers'  privacy;193 
workers  may  worry  about  the  confidentiality  of 
their  test  results  and  whether  they  will  be  used  to 
deny  employment  or  to  impose  other  forms  of 
discrimination.194  The  drug- testing  process  can 
be  costly  as  well.195  In  conducting  workplace 
drug  testing,  the  American  Society  of  Addiction 
Medicine  (ASAM)  recommends  that  a  positive 
drug  test  be  used  only  as  evidence  that  substance 
use  occurred,  not  as  evidence  of  functional 
impairment  or  addiction;  the  interpretation  of 
drug  test  results  should  include  the  use  of  a 
credentialed  Medical  Review  Officer;  and 
controlled  prescription  medications  should  be 
included  in  the  screening.196 

Government-Funded  Social  Service 
Systems 

Government  agencies  can  play  an  important  role 
in  providing  screening  and  brief  interventions  to 
a  range  of  clients  including  those  receiving 
housing,  welfare  and  child  protection,  services 
for  the  elderly,  and  in  HIV  and  STD  clinics.197 
Government- funded  social  service  systems  can 
identify  substance  use  risk  in  individuals 
participating  in  their  programs  and  provide 
interventions,  treatments  or  referrals  to  specialty 
care  when  addiction  is  identified. 

A  significant  proportion  of  individuals  who 
participate  in  government  programs  have  many 
risk  factors  for  substance  use  and  addiction  and 
can  benefit  from  screening  and  brief  intervention 
services.  Identifying  individuals  at  risk  and 
providing  effective  interventions  for  those  in 
need  may  help  to  reduce  their  risk  of  further 
substance  use,  job  loss,  domestic  violence  and 
other  crime  and,  ultimately,  can  lead  to  cost- 
savings  through  decreased  demand  for 
government  services.198  Despite  the  logic  of  this 
approach,  there  is  little  research  on  the 
effectiveness  of  screening  and  brief 
interventions  in  these  populations  and,  instead  of 
implementing  these  services,  some  states  are 
now  imposing  or  considering  drug  testing  as  a 
precondition  for  cash  assistance  and  other 


services  and  a  basis  for  denying  both  program 
eligibility  and  needed  medical  care.*  199 

Barriers  to  Effective 
Implementation  of  Screening  and 
Brief  Interventions 

The  failure  of  our  health  care  providers,  schools, 
employers,  justice  programs  and  social  service 
programs  to  implement  effective  screening,  brief 
interventions  and  treatment  referrals  for  those 
who  engage  in  risky  use  of  addictive  substances 
represents  a  tremendous  missed  opportunity  to 
help  countless  Americans  avoid  the  far-reaching 
consequences  of  risky  use  and  the  disease  of 
addiction.  A  significant  barrier  to  change  is  the 
fact  that  services  aimed  at  preventing  and 
addressing  risky  use  and  addiction  traditionally 
have  not  been  paid  for  by  health  insurance  plans; 
as  a  result,  there  are  few  incentives  for  health 
professionals  to  make  them  a  priority  in  the  care 
of  their  patients.  To  close  the  gap  in  needed 
services,  specific  barriers  in  addition  to 
insufficient  funding  must  be  addressed, 
including  insufficient  training  of  health  care  and 
other  professionals  and  a  lack  of  specialty  care 
providers;  competing  priorities  and  insufficient 
resources;  and  inadequate  screening  tools.200 

Insufficient  Training 

Many  physicians  and  other  health  professionals 
do  not  screen  their  patients  for  risky  use  of 
addictive  substances,  provide  early  interventions 
or  treat  or  refer  for  specialty  care,  or  they  do  so 
inadequately  because  they  simply  have  not  been 
properly  trained.1  Education  about  risky  use  and 
the  disease  of  addiction,  their  impact  on  a 
patient's  health  and  other  medical  conditions, 
and  how  to  implement  screening,  interventions 
and  treatment  is  not  sufficiently  integrated  into 
medical  education  or  residency  training 
programs.201  Among  those  programs  that  do 
address  substance  use  and  addiction,  many  have 
shortcomings  in  the  curriculum  such  as 
insufficient  instruction,  limited  number  of 


The  Constitutionality  of  these  policies  is  being 
tested  in  the  courts. 
1  See  Chapters  IX  and  X. 


-81- 


courses  and  limited  time  spent  in  courses  on  the 
topic  of  addiction.202 

Inadequate  training  in  risky  use  and  addiction 
means  that  many  physicians  do  not  recognize 
these  conditions  in  their  patients,  do  not  believe 
that  substance-related  interventions  are 
effective,203  are  unaware  of  what  do  with  a 
patient  who  screens  positive  for  risky  use  or 
addiction  or  are  uninformed  about  effective 
resources  to  which  they  could  refer  patients  in 
need  of  more  in-depth  assessment  or  of  specialty 
treatment.204 

Most  schools  lack  employees  or  consulting 
personnel  with  the  necessary  training  and 
resources  for  identifying  students  who  engage  in 
risky  use  of  addictive  substances  and  attaining 
appropriate  intervention  services  for  those 
students  who  need  them.205  CASA  Columbia's 
survey  of  school  personnel  conducted  for  its 
201 1  report,  Adolescent  Substance  Use: 
America 's  #1  Public  Health  Problem,  found  that 
three-fourths  of  teachers  are  unable  to  identify  a 
professional  in  their  schools  who  would  be  able 
to  help  students  with  a  substance  use  problem. 
Only  26.9  percent  of  teachers  report  that  their 
schools  train  educators  and  other  school  staff  to 
identify  and  respond  to  student  substance  use.206 
Other  national  surveys  likewise  find  that  high 
school  counselors  and  school  psychologists 
generally  report  low  competence  in  providing 
direct  substance-related  intervention  services  to 
students  and  a  lack  of  relevant  opportunities  to 
become  trained  in  doing  so.207  Most  schools 
have  not  set  up  partnerships  with  health  care 
providers  trained  in  conducting  screening  or 
early  interventions  to  refer  students  who  engage 
in  risky  use  nor  do  they  have  links  to  appropriate 
treatment  programs  to  which  they  refer  students 
with  addiction.208 

CASA  Columbia's  1999  report,  No  Safe  Haven: 
Children  of  Substance-Abusing  Parents,  found 
that  insufficient  training  among  most  child 
welfare  workers  and  family  court  judges  greatly 
contributes  to  the  lack  of  effective  screening 
practices  in  the  child  welfare  system.209  CASA 
Columbia's  research,  published  in  its  2010 
report  Behind  Bars  II:  Substance  Abuse  and 
America's  Prison  Population,  found  that 


probation  and  parole  officers  in  the  justice 
system  need  to  be  better  trained  as  well.210 

A  related  barrier  to  screening  for  risky  use  of 
addictive  substances  and  providing  brief 
interventions  is  the  lack  of  effective  and 
appropriate  specialty  treatment  services 
available  for  referral  when  addiction  is 
identified.211  Although  having  more  trained 
addiction  physician  specialists  is  critical  to 
providing  care  for  those  with  severe  forms  of  the 
disease,  the  lack  of  such  specialty  providers  is 
not  a  legitimate  barrier  to  providing  screening 
and  brief  interventions.  Neither  is  it  a  legitimate 
reason  for  general  health  care  professionals  to  be 
unprepared  to  provide  addiction  treatment  that 
does  not  require  specialty  care.  These  services 
are  designed  to  be  provided  in  non-specialty  care 
settings,  along  with  some  forms  of  assessment 
and  treatment  (see  Chapter  V).  The  real  barrier 
in  this  case  remains  the  lack  of  knowledge  about 
risky  use  and  addiction  and  insufficient  training 
in  addressing  these  issues  among  health 
professionals. 

Competing  Priorities/Insufficient 
Resources 

Lack  of  time  and  resources  in  the  face  of 
competing  priorities  is  one  of  the  most 
prominent  barriers  to  implementation  of 
screening  and  brief  interventions  among  health 

213 

professionals,     school  personnel  and 

214 

government  agencies. 

Because  the  general  model  in  medicine  today 
(which  is  reflected  or  driven  by  insurance 
reimbursement  structures)  is  procedure-oriented 
and  reactive  more  than  preventive,  and  because 
insurance  coverage  for  screening  and  brief 
interventions  for  substance  use  has  been  rare,* 
these  services  end  up  falling  low  on  most 
physicians'  lists  of  competing  priorities  for  their 
time  and  attention.215 

Schools  and  government  agencies  that 
administer  justice  programs  or  provide  social 
services  also  face  competing  priorities  and 
financial  constraints  that  serve  as  barriers  to 


See  Chapter  VIII. 


-82- 


their  implementation  of  screening  and  brief 
intervention  services.216  Too  often,  state 
policymakers  or  administrators  of  these 
programs  fail  to  understand  how  risky  use  and 
addiction  impede  progress  in  achieving  their 
organizational  goals. 

The  priorities  of  protecting  patient 
confidentiality  and  maintaining  an  amicable  and 
trusting  doctor-patient  relationship  also  may 
impede  health  professionals'  implementation  of 
these  practices.217  While  existing  federal 
regulations*  protect  the  privacy  of  patients 
receiving  addiction-related  services  in  settings 
that  are  federally  assisted  and  that  are  primary 
providers  of  these  services,  the  regulations  do 
not  apply  to  other  service  venues.218  These 
ambiguous  rules  serve  as  a  disincentive  to  health 
professionals  to  offer  screening  and  brief 
intervention  services  and  an  incentive  to  keep 
substance-related  services  divorced  from 
mainstream  medicine.219 

Inadequate  Screening  Tools 

Another  barrier  to  the  effective  implementation 
of  screening  and  brief  intervention  has  been  that 
widely-used  screening  tools  do  not  adequately 
identify  the  full  range  of  incidences  of  risky 
use.1  These  tools  also  do  not  follow  consistent 
standards  nor  are  they  designed  to  be  tailored  to 
the  unique  patterns,  symptoms  and 
consequences  of  substance  use  of  different  age 
groups,  genders,  races/ethnicities  and  cultures  or 
of  individuals  with  co-occurring  conditions,  for 
whom  a  lower  level  of  use  may  constitute  risk 
relative  to  an  average  respondent.1  220  Further, 
most  screening  instruments  focus  on  specific 
substances  independently  rather  than  identifying 
risky  use  of  all  addictive  substances  or  risk  for 
addiction  as  a  unified  disease.  Reliance  on 


Known  as  42  CFR,  Part  2  (Confidentiality  of 
Alcohol  and  Drug  Abuse  Patient  Records). 
1  See  Appendix  H. 

*  For  example,  any  use  of  addictive  substances  by 
children,  adolescents  or  pregnant  women  constitutes 
risky  use;  risky  alcohol  use  is  defined  differently  for 
women  vs.  men;  and  substance  use  by  some 
individuals  with  co-occurring  health  conditions  poses 
extreme  risks  even  at  levels  that  may  be  considered 
relatively  safe  among  those  without  such  conditions. 


instruments  that  screen  only  for  one  type  of 
substance  increases  the  likelihood  that  risky  use 
will  not  be  adequately  detected  or  that 
interventions  will  fail  to  reduce  risky  use  across 
the  board. 

Only  a  few  screening  instruments  have 
undergone  rigorous  scientific  examination  to 
determine  their  reliability,  validity,  sensitivity 
and  specificity-key  elements  determining  the 
effectiveness  of  such  instruments.5  221  Rather 
than  using  objective  and  standardized  measures 
of  risky  use  and  risk  for  addiction,  many  of  the 
more  commonly-used  screening  instruments 
determine  risk  by  relying  on  respondents' 
subjective  reports  of  their  own  reactions  to  their 
use  of  addictive  substances  and  the  reactions  of 
those  around  them,  or  their  experiences  of 
adverse  social  and  health  consequences 
associated  with  such  use.  For  example,  while 
risky  alcohol  use  commonly  is  defined  simply  as 
drinking  in  excess  of  the  established  dietary 
guidelines  of  no  more  than  one  drink  per  day  for 
women  and  two  drinks  per  day  for  men,  the 
CAGE  Questionnaire  simply  asks  four  items 
related  to  the  respondent's  alcohol  use--(l)  Have 
you  ever  felt  you  should  Cut  down  on  your 
drinking?  (2)  Have  people  Annoyed  you  by 
criticizing  your  drinking?  (3)  Have  you  ever  felt 
bad  or  Guilty  about  your  drinking?  (4)  Have  you 
ever  had  a  drink  first  thing  in  the  morning  to 
steady  your  nerves  or  to  get  rid  of  a  hangover 
(Eye-opener)?222— none  of  which  assesses 
directly  the  quantity  and/or  frequency  of  use. 

Likewise,  the  CRAFFT,  a  six-item  questionnaire 
for  screening  adolescents  for  risky  alcohol  and 
other  drug  use  (excluding  nicotine)  asks:  (1) 
Have  you  ever  ridden  in  a  Car  driven  by 


s  See  Appendix  H.  Reliability  is  whether  the 
instrument  produces  the  same  results  under  the  same 
conditions  when  taken  on  multiple  occasions. 
Validity  is  how  accurately  the  instrument  measures 
what  it  is  intended  to  measure.  Sensitivity  refers  to 
an  instrument's  ability  to  identify  correctly  the 
presence  of  a  condition;  the  higher  the  sensitivity  the 
less  likely  the  instrument  is  to  produce  false 
positives.  Specificity  is  an  instrument's  ability  to 
identify  correctly  those  without  the  condition;  the 
higher  the  specificity,  the  less  likely  the  instrument  is 
to  produce  false  negatives. 


-83- 


someone  (including  yourself)  who  was  high  or 
had  been  using  alcohol  or  drugs?  (2)  Do  you 
ever  use  alcohol  or  drugs  to  Relax,  feel  better 
about  yourself  or  fit  in?  (3)  Do  you  ever  use 
alcohol  or  drugs  while  you  are  by  yourself 
Alone?  (4)  Do  you  ever  Forget  things  you  did 
while  using  alcohol  or  drugs?  (5)  Do  your 
Family  or  Friends  ever  tell  you  that  you  should 
cut  down  on  your  drinking  or  drug  use?  (6)  Have 
you  ever  gotten  into  Trouble  while  you  were 
using  alcohol  or  drugs?  An  affirmative  answer 
to  each  question  is  worth  one  point  and  a  cut-off 
score  of  two  is  recommended  for  identifying 
risky  alcohol  and  other  drug  use,223  even  though 
any  use  of  addictive  substances  by  adolescents  is 
considered  risky.224 

The  typical  screening  process  also  may  fail  to 
distinguish  those  individuals  with  a  higher  level 
of  substance  involvement  and  the  associated 
health  and  social  consequences  (including  the 
risk  for  addiction)  from  those  with  lower  levels 
of  involvement— a  distinction  necessary  for 
providing  appropriate  interventions.225 


Chapter  V 

Treatment  and  Management  of  Addiction 


Addiction  is  a  disease  that  can  be  treated  and 
managed  effectively  at  venues  where  regular 
medical  care  is  delivered  by  physicians, 
including  addiction  physician  specialists,  and 
including  a  multi-disciplinary  team  of  other 
health  professionals  using  an  array  of  evidence- 
based  pharmaceutical  and  psychosocial f 
approaches.  In  accordance  with  standard 
medical  practice  for  the  treatment  of  other 
chronic  diseases,  best  practices  for  the  effective 
treatment  and  management  of  addiction  must  be 
consistent  with  the  scientific  evidence  of  the 
causes  and  course  of  the  disease.  Best  practices 
require:1 

•    Comprehensive  assessment  of  the  extent 
and  severity  of  the  disease,  determination  of 
a  clinical  diagnosis,  evaluation  of  co- 
occurring  health  conditions  and  the 
development  of  a  tailored  treatment  plan; 


In  this  report,  we  have  used  the  general  term 
addiction  to  apply  to  those  who  meet  criteria  for  past- 
month  nicotine  dependence  based  on  the  Nicotine 
Dependence  Syndrome  Scale  (NDSS)  and  those  who 
meet  diagnostic  criteria  for  past  year  alcohol  and/or 
other  drug  abuse  or  dependence  (excluding  nicotine) 
in  accordance  with  the  Diagnostic  and  Statistical 
Manual  of  Mental  Disorders  (DSM-IV).  (The  DSM 
refers  to  substance  abuse  and  substance  dependence 
collectively  as  substance  use  disorders.  The  criteria 
for  nicotine  dependence  in  the  NDSS  parallel  those 
of  the  DSM-IV.)  This  definition  is  consistent  with 
the  current  move  to  combine  abuse  and  dependence 
into  an  overarching  diagnosis  of  addiction  in  the 
upcoming  DSM-V. 

f  Psychosocial  therapy  is  a  general  term  for  non- 
pharmaceutical-based  interventions  and  includes 
various  forms  of  individual  and  group  psychotherapy 
that  address  psychological,  behavioral  and  social 
issues  that  contribute  to  risky  substance  use  and 
addiction.  Behavioral  therapies  are  those 
psychosocial  interventions  that  focus  more  directly 
on  addressing  the  patient's  substance-related 
behaviors,  typically  through  behavioral  reinforcement 
approaches,  with  less  of  an  emphasis  on  the 
psychological  or  social  determinants  of  their 
substance  use. 


-85- 


•  Stabilization  of  the  patient's  condition  via 
cessation  of  substance  use  and  medically 
supervised  detoxification,  when  necessary, 
as  a  precursor  to  treatment; 

•  Acute  Care  via  evidence-based 
pharmaceutical  and/or  psychosocial 
addiction  treatments,  accompanied  by 
treatment  for  co-occurring  health  conditions, 
delivered  by  qualified  health  professionals; 

•  Chronic  Disease  Management  to  help  the 
patient  maintain  the  progress  achieved 
during  acute  treatment  and  prevent  relapse. 
The  process  should  be  medically  supervised 
and  should  involve  pharmaceutical  and/or 
psychosocial  therapies  and  continued 
management  of  co-occurring  health 
conditions  as  indicated;  and 

•  Support  Services  including  encouragement 
to  participate  in  mutual  support  programs 
and  the  provision  of  auxiliary  support 
services  such  as  legal,  educational, 
employment,  housing  and  family  supports. 

A  Comprehensive  Approach  to 
Treatment 

A  comprehensive  approach  to  addiction  requires 
recognition  of  addiction  as  a  primary  disease  and 
that  all  substances  and  behaviors  associated  with 
addiction  are  addressed  in  treatment,  rather  than 
a  focus  only  on  an  individual  addictive 
substance.  It  is  all  too  common,  for  example, 
for  addiction  involving  nicotine  to  be  ignored  in 
the  course  of  treating  addiction  involving 
alcohol  or  other  drugs.  Accordingly,  when 
treating  addiction,  it  is  critical  to  recognize  the 
high  rates  of  co-occurrence  of  different 
manifestations  of  addiction  and  the  possibility  of 
the  existence  of  an  addiction  syndrome,  in  which 
common  pathways  underlie  related  addictive 
behaviors  (e.g.,  obesity  or  bulimia  and  addiction 
involving  alcohol)  and  in  which  individuals  may 
switch  from  one  object  of  addiction*  to  another 
(e.g.,  from  prescription  opioids  to  heroin,  from 
addictive  substances  to  pathological  gambling).5 


Including  the  source  of  reward  or  relief. 


Similarly,  treatments  for  one  manifestation  of 
addiction  tend  to  have  spillover  effects,  either 
ameliorating  the  symptoms  of  other 
manifestations  of  addiction  or  proving  effective 
in  the  treatment  of  multiple  expressions  of 
addiction  (e.g.,  naltrexone  for  the  treatment  of 
addiction  involving  opioids,  alcohol  as  well  as 
gambling).6 


When  treatment  is  too  highly  focused  on  a 
specific  substance  or  behavior,  it  may  not  be 
addressing  the  actual  underlying  causes  of  the 
addiction  or  the  possibility  of  "addiction 


Numerous  studies  have  shown  that  addiction 
treatments  are  just  as  effective  as  those  for  other 
illnesses.2 

-Alan  I.  Leshner,  PhD 
Chief  Executive  Officer 
American  Association  for  the 
Advancement  of  Science 
Executive  Publisher,  Science 
Former  Director 
National  Institute  on  Drug  Abuse  (NIDA) 

/7  would  define  treatment  for  addiction]  the  way  I 
would  define  treatment  for  any  medical  problem- 
good  thorough  evaluation,  intervention  tailored 
for  that  specific  person  based  on  a  good 
assessment,  use  of  a  range  of  tools— behavioral, 
pharmacological,  family  and  other  social  support, 
housing,  jobs? 

—John  Rotrosen,  MD 
Professor,  Department  of  Psychiatry 
New  York  University  School  of  Medicine 
VA  NY  Harbor  Healthcare  System 

The  goal  of  the  'good  and  modern '  system  is  to 
provide  a  full  range  of  high-quality  services  that 
meet  the  range  of  age,  gender,  cultural  and  other 
circumstances  that  the  individual  brings  to 
treatment.  It  is  grounded  in  a  public  health  model 
that  addresses  system  and  service  coordination; 
health  promotion  and  prevention,  screening  and 
early  intervention;  treatment  and  recovery;  and 
resiliency  supports  to  promote  social  integration 
and  optimal  health  and  productivity? 

~H.  Westley  Clark,  MD,  JD,  MPH 
Director 

Center  for  Substance  Abuse  Treatment,  SAMHSA 


-86- 


hopping,"  where  a  patient  replaces  one  addiction 
object  with  another.  Treating  the  disease  of 
addiction  involves  addressing  not  only  the 
specific  object  of  the  addiction,  but  the 
antecedents,  manifestations  and  consequences  of 
addiction  more  generally.7 


addiction  diagnosis,  establish  whether  co- 
occurring  medical,  including  mental  health, 
problems  exist  and  allow  for  the  development  of 
an  appropriate  and  specific  treatment  plan.10 

Assessment  tools,  as  distinguished  from 
screening  tools,  are  meant  to  determine  the 
presence  and  severity  of  a  clinical  condition  and 
should  parallel,  at  least  in  part,  established 
diagnostic  criteria  for  the  disease.1  Assessments 
tools  also  might  examine  social,  family  and 
personal  factors  that  might  relate  to  or  co-occur 
with  substance  use. 1 1  This  information  can  help 
health  care  practitioners  determine  the  most 
appropriate  intervention  for  their  patients. 

A  comprehensive  assessment  helps  to  create  the 
foundation  for  effective  treatment  that  is 
individualized  and  tailored  to  the  patient.5  12 
The  assessment  should  gather  information  about 
many  aspects  of  the  individual  including  the 
physiological,  behavioral,  psychological  and 
social  factors  that  contribute  to  the  patient's 
substance  use  and  that  might  influence  the 
treatment  process.13  For  example,  in  addition  to 
determining  the  patient's  health  status,  the  stage 
and  severity  of  the  disease14  and  the  family 
history  of  addiction,  the  assessment  should 
determine  personality  traits  such  as 
temperament;  family  and  social  dynamics;  the 
extent  and  quality  of  the  patient's  family  and 
social  support  networks;  prior  treatment 
attendance  and  response  to  previous  treatment 
experiences;15  and  the  patient's  motivation  and 
commitment  to  disease  management. 
Assessments  also  should  cover  the  situations  and 
behaviors  that  may  increase  risk  for  relapse  and 
those  that  protect  against  relapse.16  It  is 
important  that  assessment  instruments  also  offer 
some  degree  of  cultural  sensitivity  and  that  they 
are  age  and  gender  appropriate.17 


'  See  Appendix  H  for  some  examples  of  assessment 
instruments  used  by  practitioners  and  researchers  to 
help  make  these  diagnoses. 

*  This,  however,  is  not  always  the  case  in  commonly- 
used  assessment  instruments  (see  Appendix  H). 
§  Much  of  the  research  on  comprehensive 
assessments  relates  to  addiction  involving  alcohol. 


The  bottom  line  is  that  addiction  is  an  illness  that 
we  are  able  to  treat  and  manage,  if  not  cure, 
provided  that  we  focus  on  the  person  with  the 
addiction,  the  family  and  the  community— a 
holistic  approach  to  a  sprawling  problem* 

-Harold  S.  Koplewicz,  MD 
Child  and  Adolescent  Psychiatrist 
President 
Child  Mind  Institute 


Assessment 

Once  a  patient  has  been  screened  for  risky  use 
and  identified  as  requiring  professional  services 
beyond  a  brief  intervention,  a  physician- 
working  with  other  health  professionals-should 
perform  a  comprehensive  assessment  of  the 
patient's  medical,  psychological  and  substance 
use  history  and  current  health  status,  present 
symptoms  of  addiction,  potential  withdrawal 
syndrome  and  related  addictive  behaviors.  This 
thorough  assessment  is  a  necessary  precursor  to 
treatment  initiation  and  must  involve  a  trained 
physician.9  The  assessment  should  utilize 
reliable  and  valid  interview-based  instruments 
and  biological  tests  as  needed.  The  goals  of  the 
assessment  are  to  help  the  provider  determine 
the  nature,  stage  and  extent  of  the  disease  and 
whether  the  patient  meets  clinical  criteria  for  an 


Despite  the  distinction  between  screening  and 
assessment  tools,  the  term  screening  often  is  used  to 
subsume  the  concept  of  assessment  or 
interchangeably  with  the  term  in  the  clinical  and 
research  literatures.  Furthermore,  while  there  is  some 
overlap  between  screening  or  assessment  procedures 
used  to  identify  risky  substance  use  and  methods 
used  to  diagnose  a  clinical  addiction,  a  formal 
diagnosis  of  addiction  should  be  based  on  the 
demonstration  of  specific  symptoms  included  in  the 
most  recent  versions  of  the  Diagnostic  and  Statistical 
Manual  of  Mental  Disorders  (DSM)  or  the 
International  Statistical  Classification  of  Diseases 
(see  Chapter  II). 


-87- 


The  comprehensive  assessment  should  result  in 
a  treatment  plan  that  is  developed  in  concert 
with  the  patient  by  a  physician  with  input  from 
other  health  professionals.  The  treatment  plan 
should  articulate  clearly  the  treatment  goals  and 
particular  interventions  aimed  at  meeting  each  of 
those  goals.  The  plan  should  be  monitored  and 
revised  as  needed  should  the  patient's  status  or 
needs  change.18 

The  comprehensive  assessment  also  should 
result  in  a  detailed  and  thorough  written  report, 
which  should  be  incorporated  into  the  patient's 
health  record,  that: 

•  Provides  a  clinical  diagnosis  and  identifies 
the  particular  manifestations  and  severity  of 
the  disease; 

•  Identifies  factors  that  contribute  to  or  are 
related  to  the  disease; 

•  Identifies  a  treatment  plan  to  address  these 
risk  factors  and  ensure  that  the  treatment 
plan  is  implemented  and  monitored 
effectively;  and 

•  Provides  connections  to  specialty  care— i.e., 
an  addiction  physician  specialist  or  other 
specialty  providers-as  needed  and  to 
auxiliary  and  support  services.19 

Stabilization* 

The  first  step  in  addressing  addiction  involving 
nicotine,  alcohol  or  other  drugs  is  cessation  of 
use  and,  if  necessary,  medically  managing  the 
clearance  of  toxic  substances  from  the  patient's 
system  via  a  clinical  process  often  referred  to  as 
detoxification.  Detoxification  itself  addresses 
intoxication  or  withdrawal  but  is  not  treatment 
of  addiction.20  In  most  cases,  cessation  of  use  is 
the  necessary  first  step  to  formal  treatment 
protocols.  While  cessation  of  use  can  in  some 


Note  that  some  of  the  medications  described  for  use 
in  the  stabilization  (tobacco  cessation  and 
alcohol/other  drug  detoxification)  process  will  be 
described  in  greater  detail  later  in  this  chapter  in  the 
discussions  of  acute  treatments  for  addiction  and 
chronic  disease  management. 


cases  be  a  self-managed  process,  patients 
typically  need  professional  assistance. 

Cessation  of  Use 

Tobacco.  Smoking  cessation,  while  unpleasant 
for  most  persons  going  through  it,  is  not  unsafe 
and  does  not  require  medical  monitoring. 
Patients  undergoing  smoking  cessation  may 
experience  certain  withdrawal  symptoms 
including  cravings,  irritability,  impatience, 
hostility,  anxiety,  depressed  mood,  difficulty 
concentrating,  decreased  heart  rate,  increased 
appetite  and  sleep  disturbances.21  The  calming 
effect  many  smokers  feel  when  smoking  usually 
is  associated  more  with  the  relief  of  nicotine 
withdrawal  symptoms  than  with  the  effects  of 
the  nicotine  itself.  Withdrawal  symptoms  can 
commence  in  as  little  as  a  few  hours  after  the 
last  dose  of  nicotine,  peak  within  a  few  days, 
and  either  subside  within  several  weeks  or,  in 
some  cases,  persist  for  months.22 

Nicotine  replacement  therapy  (NRT)-through 
the  use  of  nicotine  patches,  gum,  nasal  spray, 
inhalers,  lozenges  and  sub-lingual  tablets-is  a 
common  pharmaceutical  aid  for  persons 
attempting  smoking  cessation.  NRT  lessens 
withdrawal  symptoms,  increasing  the  chance 
that  a  smoker  will  quit  successfully.23  NRT 
replaces  some  of  the  nicotine  formerly  obtained 
by  smoking.24  However,  the  nicotine  in  NRT  is 
delivered  more  slowly  and  at  lower  dose  levels 
than  through  smoking,  so  NRT  is  more  likely  to 
reduce  cravings  than  wholly  eliminate  them.25 
Some  NRTs  mimic  the  sensations  of  smoking 
(the  inhaler)  or  otherwise  occupy  the  mouth 
(gum,  lozenges  and  sub-lingual  tablets).26 
Research  indicates  that  the  most  effective  use  of 
NRT  involves  replicating  the  experience  of 
smokers:  using  nicotine  patches  to  maintain  a 
baseline  serum  nicotine  level  along  with  the  gum 
or  lozenges  to  produce  a  boost  of  serum  nicotine 
levels  periodically.27 

Other  pharmaceutical  therapies  such  as 
antidepressants  (bupropion  SR)  and  nicotine 
agonists  (varenicline)  can  help  people  quit 


-88- 


smoking  and  maintain  their  abstinence. 

Alcohol  and  Other  Drugs.  Some  patients  with 
addiction  involving  alcohol  and  other  drugs  can 
reduce  and  ultimately  cease  substance  use 
without  medical  supervision,  particularly  if  they 
are  not  physically  dependent  on  the  substances 
involved,  the  disease  is  not  advanced  and  they 
have  sufficient  personal  supports  to  help  them 
through  the  cessation  process. 

Detoxification 

For  patients  who  demonstrate  physical 
dependence  on  a  substance,  cessation  of  use  on 
their  own  may  be  unsafe  and  medically 
supervised  detoxification  may  be  required  to 
manage  withdrawal  symptoms  and 
complications.29 

Detoxification  occurs  when  toxic  substances  that 
come  from  the  ingestion  of  alcohol  or  other 
drugs  are  removed  from  the  body  via 
metabolism  through  the  liver  and  excretion 
through  the  kidneys.30  Medically-assisted 
detoxification  aims  to  reduce  the  risk  of 
discomfort  and  potential  physical  harm  for 
patients  who  are  experiencing  withdrawal.31 

The  detoxification  process  often  requires  the 
assistance  of  medical  professionals  and  may 
involve  the  use  of  pharmaceutical  therapies  to 
guide  people  safely  through  withdrawal. 
Medical  professionals  may  collaborate  with 
supportive,  non-medical  personnel  or  with 
medical  personnel  in  other  health  facilities  to 
facilitate  the  withdrawal  process.32 
Detoxification  is  an  important  and  often 
necessary  prerequisite  to  effective  acute 
addiction  treatment.33  It  should  serve  as  the 
catalyst  for  entry  into  the  treatment  system  but 
does  not  itself  constitute  treatment.34 

There  are  three  main  components  to  effective 
detoxification: 


These  medications  are  described  in  more  detail  later 
in  the  chapter. 

'  Physical  dependence  is  characterized  by  symptoms 
of  tolerance  and/or  withdrawal  (see  Chapter  II). 


1 .  Evaluation.  Examine  the  patient  and 
determine  if  symptoms  are  acutely  present- 
ideally  using  standardized  instruments  to 
measure  the  severity  of  withdrawal  35— and 
documenting  vital  signs  and  other  physical 
manifestations  of  withdrawal.  Assess  for 
the  presence  of  co-occurring  medical  and 
mental  health  conditions  and  determine, 
through  the  use  of  drug  testing,  which 
substances  are  present  in  the  person's  body 
or  were  used  recently.36 

2.  Stabilization.  Assist  patients  through 
withdrawal  to  re-establish  a  state  of 
physiological  stability  with  or  without  the 
use  of  medications.37 

3.  Facilitation  of  Treatment  Entry.  Provide  or 
connect  patients  to  addiction  treatment  and  a 
continuing  care  plan.38 

Alcohol  Detoxification.  In  alcohol 
detoxification  services,  the  cessation  of  alcohol 
ingestion  in  an  alcohol-tolerant  individual  is 
coupled  with  certain  medications  to  help  prevent 
the  dangerous  effects  that  may  accompany 
alcohol  withdrawal.  Withdrawal  from  alcohol 
typically  takes  up  to  seven  to  10  days,  but  with 
medical  management,  stabilization  can  be 
achieved  sooner. §  39  During  the  first  six  to  48 
hours  of  withdrawal  from  alcohol,  symptoms 
may  include  anxiety,  nausea,  agitation  and 
difficulty  concentrating.40  More  severe 
symptoms  can  include  hallucinations  and 
seizures.41  Alcohol  withdrawal  delirium,  also 
known  as  delirium  tremens  (DTs),  is  the  most 
severe  and  dangerous  withdrawal  symptom  and 
usually  appears  two  to  four  days  after  the  last 
drink.42  Some  symptoms  of  alcohol  withdrawal, 
including  DTs  and  seizures,  can  be  life- 


1  These  include  the  Clinical  Institute  Withdrawal 
Assessment-Alcohol  Revised  (CIWA-Ar),  the 
Clinical  Opiate  Withdrawal  Scale  (COWS)  and  the 
Finnegan  Neonatal  Abstinence  Score. 
§  The  duration  of  detoxification  varies  with  the 
severity  of  addiction  and  some  withdrawal 
symptoms,  such  as  sleep  disturbances,  may  persist  for 
several  weeks. 


-89- 


threatening.      These  withdrawal  symptoms  can 
be  more  severe  in  persons  who  have  undergone 
prior  multiple  episodes  of  alcohol  withdrawal,  a 
process  known  as  the  kindling  effect. '  44 

Benzodiazepines,  which  have  calming,  sedating 
effects,  have  been  shown  to  prevent  the  onset  of 
certain  alcohol  withdrawal  symptoms  and 
acutely  relieve  such  symptoms  including 
alcohol-induced  seizures  and  DTs.45  A  large 
review  study  found  that  whereas 
benzodiazepines  are  more  effective  than 
placebos  at  treating  seizures  in  patients  going 
through  alcohol  withdrawal,  there  is  no  evidence 
that  they  are  more  effective  than  other 
medications  used  to  treat  alcohol  withdrawal 
syndrome  or  that  particular  benzodiazepines  are 
more  effective  than  others.46  Benzodiazepines 
commonly  used  to  treat  the  anxiety  and  agitation 
symptoms  associated  with  alcohol  withdrawal 
include  diazepam,1  47  chlordiazepoxide,48 
lorazepam  and  oxazepam.49 

Because  the  combined  effects  of 
benzodiazepines  and  alcohol  can  be  life 
threatening  or  even  fatal,50  patients  must  be 
advised  not  to  drink  while  on  benzodiazepine 
medications.  This  is  particularly  important  since 
benzodiazepines  commonly  are  prescribed  for 
alcohol  withdrawal  on  an  outpatient  basis  where 
patients'  drinking  may  not  be  monitored 
adequately.51  Another  cautionary  note  is  that 
benzodiazepines  have  addictive  potential  in  their 
own  right;  therefore,  their  use  must  be 
monitored  carefully.52 

Carbamazepine,  an  anti-seizure  medication,  may 
be  an  effective  alternative  to  benzodiazepine 
medications  for  treating  alcohol  withdrawal.53 
Carbamazepine  also  may  be  effective  at 


Although  DTs  occur  only  in  about  five  percent  of 
patients  undergoing  detoxification,  mortality  from 
DTs  historically  has  been  as  high  as  18.5  percent. 
Swift  detection  and  proper  treatment  can  lower  this  to 
about  five  percent. 

'  Kindling  is  the  increase  in  neuronal  responses 
produced  by  repeated  stimulation.  Kindling  leads  to 
a  worsening  of  withdrawal  symptoms  with  each 
attempt  at  alcohol  detoxification. 
*  Diazepam  also  may  relieve  muscle  spasms  and 
seizures  associated  with  alcohol  withdrawal. 


addressing  alcohol  cravings.    The  medication's 
ability  to  treat  seizures,  the  minimal  potential  for 
misuse,  the  significant  potential  to  treat  mood 
disorder  and  the  lack  of  sedating  effects  are 
some  of  its  advantages.55 

Opioid  Detoxification.  For  patients  with 
addiction  involving  illicit  or  prescription 
opioids,  including  heroin,  hydrocodone  or 
oxycodone,  withdrawal  symptoms  are  not  life 
threatening,  but  they  can  be  extremely 
uncomfortable56  and  must  be  managed 
effectively  to  prevent  relapse.57  Opioid 
withdrawal  symptoms  can  include  abdominal 
pain,  muscle  aches,  agitation,  diarrhea,  dilated 
pupils,  insomnia,  nausea,  runny  nose,  sweating 
and  vomiting.58  Withdrawal  symptoms 
generally  last  from  seven  days  to  several 
weeks.59  Because  medical  complications  can 
develop,  patients  must  undergo  regular 
monitoring  including  physical  examinations,  a 
complete  review  of  the  functioning  of  the  body's 
organs  and  psychological  status  and,  when 
necessary,  laboratory  evaluations.60 

The  goal  of  medical  detoxification  is  a  safe, 
comfortable  and  complete  withdrawal  from 
opioids.  Abrupt  discontinuation  of  opioids, 
especially  for  a  patient  who  has  developed 
physical  dependence  on  the  drug,  typically  is  not 
recommended;  instead,  in  the  case  of  such 
dependence  involving  prescription  opioids,  the 
patient  is  tapered  or  weaned  off  the  opioid 
medication.5  61  However,  for  addiction 
involving  illicit  opioids,  it  is  not  legal  to 
prescribe  a  tapering  dose  of  the  illicit  drug  so 
another  method  must  be  used. 

An  alternative  to  tapering  is  management  of 
withdrawal  symptoms  using  non-opioid 
medications-such  as  clonidine62-to  decrease  the 
agitation  and  discomfort  associated  with  opioid 
withdrawal,  or  other  medications  that  can  relieve 
the  symptoms  of  acute  withdrawal  such  as 
nonsteroidal  anti-inflammatory  drugs  (NSAIDs) 
to  treat  muscle  pain,  antiemetics  for  nausea  and 
non-addicting  sleeping  medications  such  as 


The  use  of  a  tapering  dose  calculator  can  help  in 
this  process  and  can  be  accessed  online  at: 
www.agencymeddirectors.wa.gov/guidelines.asp 


-90- 


trazadone  to  treat  insomnia.  Detoxification 
also  can  be  achieved  using  specific  medically- 
prescribed  opioids  that  have  less  potential  for 
misuse  (methadone  or  buprenorphine)  and  then 
tapering  the  patient  off  these  medications  when 
possible.64 

The  prescription  of  methadone  for  addiction 
treatment  is  restricted  by  federal  regulations;*  it 
only  can  be  prescribed  for  detoxification  from 
opioids  in  licensed  facilities. '  65  Buprenorphine 
can  be  dispensed  or  prescribed  for  illicit  or 
prescription  opioid  withdrawal  in  any  outpatient 
setting  by  qualified  physicians  who  have  the 
required  waiver  from  the  Drug  Enforcement 
Administration  (DEA).* 66  While  use  of  these 
medically-prescribed  opioids  can  result  in 
physical  dependence,  they  are  considered  less 
dangerous  because  they  have  less  potential  for 
misuse  and  addiction  than  other  opioids;5  67  they 
also  are  prescribed  to  patients  by  a  licensed 
physician  in  a  medical  care  setting.  They  work 
by  occupying  the  opioid  receptors  in  the  brain, 
blocking  or  minimizing  the  effects  of  more 
addicting  opioid  drugs;  therefore,  a  patient  on 
methadone  or  buprenorphine  maintenance 
largely  is  protected  from  inadvertent  overdose.68 

CNS**  Stimulant  Detoxification.  Cessation  of 
CNS  stimulant  (cocaine,  amphetamine)  use  may 
result  in  withdrawal  symptoms  if  the  user 


It  is  not  restricted  when  prescribed  for  pain 
management. 

1  Unless  a  patient  has  been  hospitalized  for  another 
medical  condition. 

*  Becoming  qualified  to  prescribe  and  distribute 
buprenorphine  involves  an  eight-hour  approved 
program  in  treating  addiction  involving  opioids,  an 
agreement  that  the  physician/medical  practice  will 
not  treat  more  than  30  patients  for  addiction 
involving  opioids  with  buprenorphine  at  any  one  time 
within  the  first  year  and  up  to  100  thereafter,  and 
assurance  that  the  trained  physician  will  refer  patients 
to  necessary  supplemental  psychosocial  services. 
Physicians  who  meet  the  qualifications  are  issued  a 
waiver  by  the  Substance  Abuse  and  Mental  Health 
Services  Administration  (SAMHSA)  and  a  special 
identification  number  by  the  DEA. 
§  Methadone  and  buprenorphine  also  are  used  for 
stabilization  and  maintenance  of  addiction  involving 
opioids. 

**  Central  Nervous  System. 


develops  addiction  involving  these  drugs;  these 
symptoms  are  not  life-threatening  and  generally 
are  less  severe  than  those  associated  with 
withdrawal  from  alcohol  or  opioids/ r  69 
Symptoms  of  stimulant  withdrawal  commonly 
include  decreased  energy,  insomnia,  agitation, 
increased  appetite,  depressed  mood,  anxiety  and 
drug  craving.70 

Evidence  for  the  effectiveness  of  pharmaceutical 
detoxification  to  assist  in  stimulant  withdrawal 
is  limited.7  A  vaccine  to  treat  addiction 
involving  cocaine  and  ease  withdrawal 
symptoms  currently  is  being  tested. tt  72  But 
more  research  is  needed  to  determine  the 
vaccine's  place  in  the  cocaine  detoxification 
process  and  how  it  can  be  implemented  safely.73 
Although  there  are  no  available  medications 
proven  to  be  effective  in  mitigating  the 
symptoms  of  amphetamine  withdrawal,74  several 
medications  currently  being  researched  may 
prove  useful  in  alleviating  the  symptoms. §§  75 

CNS  Depressant  Detoxification.  Withdrawal 
from  CNS  depressants  may  produce 
complications  and,  in  some  circumstances,  can 
be  life-threatening.76  Symptoms  of  withdrawal 
from  certain  prescription  CNS  depressants,  such 
as  benzodiazepines,  are  similar  to  those  for 
alcohol  withdrawal,  with  seizures  and  delirium 
being  the  most  serious.  In  the  elderly,  there  is  a 
risk  of  falls  and  myocardial  infarctions  during 
benzodiazepine  withdrawal.77  Benzodiazepine 
withdrawal  symptoms  more  specifically  include 
seizure,  hypersensitivity,  impaired  perception  of 
movement,  nausea  and  tension.        It  is 
common  for  people  detoxifying  from 


1  During  withdrawal  from  stimulants,  there  is  a  risk 

of  depression  or  negative  thoughts  and  feelings  that 

may  lead  to  suicidal  thoughts  or  attempts. 

**  See  page  98  for  a  discussion  of  vaccines  under 

development  for  addiction  treatment. 

§§  Drugs  under  investigation  for  this  purpose  include 

modafinil,  propranolol  and  bupropion;  these 

investigations  are  of  off-label  uses  of  approved  drugs. 

Symptoms  of  withdrawal  from  benzodiazepines 
often  mimic  the  conditions  for  which  those  drugs 
initially  were  prescribed-mood  and  anxiety 
disorders.  As  such,  it  sometimes  is  unclear  if  the 
patient  is  presenting  with  withdrawal  symptoms  or 
with  symptoms  of  the  underlying  condition. 


-91- 


benzodiazepines  to  experience  significant 
withdrawal  symptoms  lasting  between  10  and  14 
days,79  and  symptoms  can  persist  for  four  to  six 
months.80  Therefore,  it  is  recommended  that 
benzodiazepine  detoxification  extend  over  a 
period  of  weeks  or  months-tapering  the  patient 
off  the  drugs  over  time.  Another  option  for 
detoxification  from  benzodiazepines  is  to 
prescribe  a  different  drug  from  the  class,  one 
with  a  longer  half-life,  such  as 
chlorodiazepoxide  or  clonazepam.81 

Detoxification  Venues.  Detoxification  can  take 
place  in  a  variety  of  settings  including  the 
patient's  home  (monitored  and  managed  by 
trained  clinicians),  physicians'  offices,  non- 
hospital  addiction  or  mental  health  treatment 
facilities,  urgent  care  centers  and  emergency 
departments,  intensive  outpatient  and  partial 
hospitalization  programs  and  acute  care  inpatient 

*  82 

settings. 

For  planned,  monitored  or  medically-assisted 
detoxification,  health-care  providers,  considering 
the  specific  needs  of  the  patient,  typically 
determine  the  venue  for  detoxification.  Patients 
should  be  placed  in  the  least  restrictive  setting 
possible.83  Beginning  in  the  1970s,  there  was  a 
movement  toward  medical  ambulatory 
detoxification,  primarily  for  alcohol,  that 
maintained  high  safety  and  efficacy  profiles  while 
being  more  cost  effective  than  inpatient 
detoxification.  Ambulatory  care  was  intended  to 
supplement  rather  than  replace  inpatient  medical 
detoxification  with  the  understanding  that  there 
were  some  people  for  whom  inpatient  care  still 
was  necessary.  The  ability  to  continue  to  meet  life 
responsibilities  as  well  as  relatively  lower  costs 
are  advantages  of  outpatient  detoxification.84 

The  primary  substance  involved  in  the  addiction, 
the  severity  of  the  symptoms  and  particular 
patient  characteristics  (e.g.,  age,  co-occurring 
substance  use  and  other  health  conditions)  all 
play  important  roles  in  determining  the 
appropriate  venue  for  detoxification.  For 


Such  as  acute  care  general  hospitals,  acute  care 
addiction  treatment  units  within  those  hospitals,  acute 
care  psychiatric  hospitals  and  other  specialty 
hospitals  licensed  to  provide  addiction  treatment. 


example,  patients  with  a  history  of  severe 
withdrawals  or  multiple  withdrawals  should  not 
be  placed  in  nonmedical  settings  for 
detoxification.85  For  patients  deemed  a  danger 
to  themselves  or  others,  medically-managed 
intensive  inpatient  treatment  or  emergency 
hospitalization  in  a  psychiatric  facility  is 
recommended.86  For  patients  with  mild  or 
moderate  withdrawal  symptoms,  outpatient 
detoxification  can  be  just  as  effective  as 
inpatient,  provided  the  patients  have  a  positive 
and  helpful  social  support  network.87 

Acute  Care 

Effective,  clinical  treatments  for  addiction 
include  a  significant  and  growing  range  of 
pharmaceutical  and/or  psychosocial  therapies 
delivered  by  qualified  health  professionals.  Due 
to  the  complex  nature  of  addiction  and  its 
physiological,  psychological  and  environmental 
risk  factors,  a  multi-pronged  approach  to  its 
treatment  that  includes  a  combination  of 
pharmaceutical  and  psychosocial  therapies 
typically  yields  the  best  results.88  Because  of  the 
extent  to  which  addiction  co-occurs  with  a  broad 
range  of  other  health  problems,  effective 
medically-managed  acute  treatment  protocols 
also  should  address  both  co-occurring  disorders 
and  patients'  nutrition  and  exercise 

on 

requirements. 

Guidelines  set  forth  by  the  American  Society  of 
Addiction  Medicine's  (ASAM)  patient 
placement  criteria  increasingly  are  being  used  by 
treatment  programs,  government  programs, 
managed  care  companies  and  other 
organizations  to  appropriately  match  patient 
needs  to  specific  treatment  services  and  to 
determine  the  appropriate  level  of  care.90 

Pharmaceutical  Therapies 

As  with  most  medical  conditions, 
pharmaceutical  therapies  can  be  an  important 
component  of  addiction  treatment,91  particularly 
for  patients  who  are  highly  motivated  to  adhere 
to  the  medication  regimen.'  92  (Table  5.1) 


1  For  less  motivated  patients,  supervised 
administration  of  the  medication  may  be  necessary. 


-92- 


Table  5.1 

Food  and  Drug  Administration  (FDA)  Approved  and  Promising  Pharmaceutical  Therapies  and 

the  Types  of  Substances  They  Address 


Type  of  Medication" 93 

Addiction 

Addiction 

Addiction 

Addiction 

Addiction 

Involving 
Alcohol 

Involving 
Nicotine 

Involving 
Cocaine 

Involving 
Opioids 

Involving 
Marijuana 

Reduce  Craving/ 
Withdrawal  Symptoms 

Acamprosate  (Campral) 

L  X 

Bupropion  (Zyban, 
Wellbutrin) 

X 

Nortriptyline  (Pamelor, 
Aventyl) 

X* 

Clonidine  (Catapres) 

X* 

Baclofen  (Kemstro, 
Lioresal,  Gablofen) 

X* 

Ondansetron  (Zofran) 

X* 

X* 

Gabapentin  (Fanatrex, 
Gabarone,  Gralise, 

X* 

Neurontin) 

Reward  Reduction  ] 

Disulfiram  (Antabuse) 

X 

Naltrexone  (Re Via, 
Depade,  Vivitrol) 

X 

X 

Varenicline  (Chantix) 

X 

Modafinil  (Provigil, 

X* 

Alertec,  Modavigil) 

Topiramate  (Topamax) 

X* 

X* 

Vaccines 

X* 

X* 

Maintenance/Medication- 

Assisted  Therapies 

Nicotine  Replacement 
Therapy  (NRT) 

X 

Methadone 

X 

Buprenorphine/Naloxone 
(Subutex,  Suboxone) 

X 

Oral  Tetrahydrocannabinol 
(THC) 

X* 

a  Some  of  these  medications  are  FDA-approved  for  treating  addiction  involving  the  particular  substance,  while 
others  are  not.  Specifically,  the  X  indicates  the  type  of  substance  for  which  the  medication  has  demonstrated 
efficacy  and  has  received  FDA-approval  for  use  in  the  treatment  of  addiction  involving  the  noted  substance.  The 
X*  notation  indicates  that  ongoing  research  is  demonstrating  promising  clinical  utility  for  the  medication  or 
research  already  has  demonstrated  clinical  utility  for  the  medication  in  treating  addiction  involving  the  noted 
substance,  but  these  medications  are  not  (yet)  approved  by  the  FDA  for  use  as  a  pharmaceutical  treatment  for 
addiction  involving  that  particular  substance.  Medications  that  have  been  approved  by  the  FDA  for  other  purposes 
can  be  prescribed  off-  label  (for  uses  other  than  that  for  which  it  received  FDA  approval)  based  on  clinical 
evidence.  However,  in  spite  of  clinical  evidence  of  efficacy,  these  medications  may  never  receive  FDA  approval 
since  adding  new  indications  to  a  medication's  FDA-approved  label  would  necessitate  significant  investments  in 
FDA-required  studies.94  


-93- 


Pharmaceutical  agents  for  addiction  treatment 
may  work  via  one  of  the  following  mechanisms 
of  action  or  by  a  combination  of  these 
mechanisms: 

•  Reducing  cravings  for  the  addictive 
substance  and/or  reducing  aversive 
withdrawal  symptoms; 

•  Creating  an  aversion  to  the  addictive 
substance  or  attenuating  the  rewarding 
effects  of  the  addictive  substance,  eventually 
limiting  its  appeal;  or 

•  Producing  moderated  effects  resembling 
those  of  the  addictive  substance  and  serving 
as  a  less  addicting  replacement  for  the 
substance  of  addiction. 

Differences  in  the  factors  that  contribute  to 
addiction  and  that  determine  how  the  disease 
will  manifest  itself  require  different  and  tailored 
approaches  to  treatment,  particularly  with  regard 
to  pharmaceutical  treatments.  For  example, 
individuals  with  addiction  involving  alcohol 
who  drink  primarily  for  the  rewarding  effects 
may  be  quite  different  biologically  from  those 
who  drink  primarily  as  a  means  of  relieving 
stress  or  reducing  negative  feelings;  as  such,  the 
efficacy  of  a  specific  pharmaceutical  treatment 
may  depend  on  whether  it  addresses  the  reward 
experienced  from  using  the  addictive  substance 
or  whether  it  serves  as  a  safer  medication  for 
providing  relief  from  negative  feelings.96 
Likewise,  certain  genetic  or  biological 
characteristics  may  determine  how  effective  a 
certain  type  of  pharmaceutical  intervention  will 
be  for  an  individual  with  addiction;  for  example, 
naltrexone  has  been  found  to  be  a  more  effective 
medication  for  the  treatment  of  addiction 


For  ease  of  presentation,  a  medication  is  categorized 
in  this  discussion  based  on  its  primary  mechanism  of 
action. 

*  In  individuals  with  a  significant  genetic 
susceptibility,  progression  from  use  to  addiction  is 
relatively  quick  and  severe,  whereas  in  individuals 
with  a  low  genetic  susceptibility,  progression  from 
use  to  addiction  will  result  from  prolonged  exposure 
to  addictive  substances  and  considerable 
environmental  risk  factors,  such  as  stress.  (See 
Chapter  II.) 


involving  alcohol  in  patients  with  a  family 
history  of  the  disease  than  in  those  without  a 
family  history.97  A  true  understanding  of  these 
differences  is  in  its  infancy,  but  appears  to  be  a 
critical  factor  in  tailoring  pharmaceutical 
treatments  to  achieve  the  maximum  therapeutic 
benefit.98 


Medications  that  Reduce  Craving  and/or 
Withdrawal  Symptoms.  A  number  of 
medications  work  on  the  brain  chemicals  and 
pathways  of  individuals  with  addiction  to  reduce 
cravings  for  the  addictive  substance  and  in  some 
cases  reduce  symptoms  of  withdrawal  from  the 
substance. 

Acamprosate  (brand  name  Campral),  approved 
by  the  Food  and  Drug  Administration  (FDA)  in 
2004  to  treat  addiction  involving  alcohol,  helps 
to  normalize  brain  activity  and  function  that  has 
been  disrupted  by  heavy  alcohol  use99  and 
reduce  withdrawal  symptoms  such  as  anxiety 
and  insomnia.100  It  is  prescribed  for  treatment 
patients  who  have  discontinued  their  use  of 
alcohol.101 

Studies  regarding  the  effectiveness  of 
acamprosate  have  been  mixed  in  the  U.S.,  but 
more  consistently  positive  in  Europe.1 102 
Several  large-scale,  controlled  studies  have 
found  that  acamprosate  can  double  the 
abstinence  rate  among  treatment  patients  at  one 
to  two  years  following  program  completion 
compared  to  patients  who  receive  placebos,  and 


1  The  differences  in  effectiveness  findings  appear  to 
be  due  to  methodological  differences. 


What  we  hope  to  do  is  to  actually  have  a  menu 
of  treatments  that  clinicians  could  choose  from. 
If  one  drug  doesn't  work  or  they  can't  tolerate 
it,  "  patients  would  "try  another  one  and  so 
forth,  and  hopefully  they  '11  find  one  that  is 
effective. 

-Raye  Z.  Litten,  PhD 
Associate  Director 
Division  of  Treatment  and  Recovery  Research 
National  Institute  on  Alcohol  Abuse 
and  Alcoholism  (NIAAA) 


-94- 


is  associated  with  better  treatment  retention 
rates.103  Acamprosate  generally  is  safe  to  use,  as 
it  does  not  appear  to  have  a  potential  for 
addiction,  has  virtually  no  overdose  risk,  has 
mostly  mild  side  effects  and  does  not  interact 
significantly  with  other  medications.104 

Antidepressant  medications  also  have  proven  to 
be  effective  in  smoking  cessation.  The 
mechanism  driving  the  efficacy  of 
antidepressants  as  cessation  agents  is  not  yet 
fully  understood.  It  may  be  that  antidepressant 
medications  compensate  for  nicotine's  anti- 
depressive  effects  during  withdrawal,  lessening 
this  withdrawal  symptom.  Alternatively, 
antidepressant  medications  may  work- 
independent  of  their  antidepressant  qualities—on 
the  neural  pathways  or  the  nicotine  receptors 
that  are  active  in  addiction  involving  nicotine.* 

105 

•    Bupropion  sustained  release  (SR)  (brand 
names  Zyban  and  Wellbutrin)  is  a 
prescription  antidepressant  medication  that 
can  be  used  alone  or  in  combination  with 
nicotine  replacement  therapy  (NRT)  for 
smoking  cessation.105  It  is  believed  to  work 
by  minimizing  cravings  and  withdrawal 
symptoms  during  the  early  stages  of  tobacco 
cessation.107  Bupropion  may  be  effective  in 
relieving  negative  mood  and  feelings  that 
smokers  may  experience  when  going 
through  smoking  cessation.108  The 
neurological  effects  of  bupropion  that  aid  in 
its  efficacy  as  a  cessation  medication  may 
include  blocking  the  re-uptake  of  two 
neurotransmitters  that  are  active  in  addiction 
involving  nicotine— dopamine  and 
norepinephrine— and  blocking  nicotine 
receptors.109  The  medication  reduces  the 
severity  of  nicotine  withdrawal  and  the 
depression  that  may  accompany  smoking 
cessation.110  Another  advantage  of 
bupropion  for  smoking  cessation  is  that  it 
tends  to  lessen  the  weight  gain  that  often 
accompanies— and  derails-smoking 
cessation  attempts.111 


For  example,  by  blocking  nicotine  receptors  in  the 
brain. 


Patients  generally  are  advised  to  begin  daily 
bupropion  treatment  one  to  two  weeks  prior 
to  quitting  so  that  adequate  blood  levels  of 
the  medication  can  be  reached.112  The 
standard  course  of  treatment  is  seven  to  12 
weeks,  although  this  period  can  be  extended 
for  up  to  six  months  if  necessary.113 
Possible  side  effects  include  insomnia,  dry 
mouth,  nausea  and  a  small  risk  of 
seizures.114  Bupropion  SR  carries  a  black 
box  warning'  of  increased  suicidal 
tendencies  among  children,  adolescents  and 
young  adults.115 

A  meta-analysis  of  24  bupropion  studies 
found  that  the  drug  can  nearly  double 
smokers'  chances  of  achieving  abstinence 
lasting  longer  than  five  months  compared  to 
a  placebo.116  Other  analyses  found  similar 
results.117  The  efficacy  of  the  drug  does  not 
seem  to  be  sensitive  to  longer  follow-up 
periods  (up  to  12  months),  treatment  setting, 
dosage  or  the  level  of  supplementary 
psychosocial  therapy.118 

Bupropion  also  may  be  a  promising 
treatment  for  methamphetamine  addiction;  it 
appears  to  reduce  cravings  and  the 
rewarding  effects  of  methamphetamine.119 
However,  evidence  supporting  its  ability  to 
increase  abstinence  rates  is  mixed  and 
further  research  is  needed  to  establish 
bupropion  as  an  effective  treatment  for 
methamphetamine  addiction.120 

•    Preliminary  research  indicates  that  another 
antidepressant,  nortriptyline  (brand  names 
Pamelor  and  Aventyl),  may  be  an  effective 
smoking  cessation  aid.121  Nortriptyline  has 
been  found  to  double  patients'  chances  of 
cessation  compared  to  placebos.122 
However,  the  medication  has  not  yet  been 
approved  by  the  FDA  for  use  as  a  smoking 
cessation  aid;  therefore,  it  only  is 
recommended  for  use  by  patients  who  have 
not  responded  well  to  NRT  or  bupropion.123 


'  A  black  box  warning  from  the  FDA  denotes  the 
most  serious  warning  of  adverse  effects  for  a 
medication. 


-95- 


Clonidine  (brand  name  Catapres),  a  medication 
normally  used  to  lower  blood  pressure,  may 
reduce  withdrawal  symptoms  and  assist  in 
smoking  cessation.124  However,  the  many  side 
effects  associated  with  clonidine  suggests  that  it 
only  be  prescribed  to  patients  seeking  to  quit 
smoking  if  they  are  unwilling  or  unable  to  use 
other  first-line  cessation  medications.125 

Baclofen  (brand  names  Kemstro,  Lioresal  and 
Gablofen),  a  medication  normally  used  to  treat 
spasticity,  has  been  found  to  reduce  cravings  and 
withdrawal  symptoms  in  patients  with  addiction 
involving  alcohol,  helping  them  to  reduce  their 
drinking  and  to  achieve  and  maintain  abstinence; 
however,  the  existing  evidence  is  too  limited  to 
recommend  baclofen  for  addiction  involving 
alcohol.126  A  double-blind  placebo-controlled 
study  in  humans  found  that  more  baclofen 
patients  than  placebo  patients  achieved  and 
maintained  abstinence  (70.0  percent  vs.  21.1 
percent);  baclofen  patients  also  demonstrated  a 
larger  reduction  in  average  number  of  drinks, 
alcohol  craving,  relapse  rates  and  anxiety  levels 
relative  to  placebo  patients  in  this  study.127 
There  appears  to  be  a  dose-response  relationship 
for  baclofen,  with  greater  effectiveness  at  higher 
doses.128 

Ondansetron  (brand  name  Zofran),  an  anti- 
nausea drug,129  has  been  shown  to  be  effective  in 
reducing  alcohol  use  cravings  and  alcohol  use 
among  patients  with  addiction  involving  alcohol, 
particularly  among  those  with  an  early  onset 
addiction.130  The  drug  may  be  more  effective  in 
patients  with  specific  genotypes. '  131  There  also 
is  emerging  evidence  that  ondansetron  might  be 
effective  in  treating  withdrawal  symptoms  in 
patients  with  addiction  involving  opioids.132 

Gabapentin  (brand  names  Fanatrex,  Gabarone, 
Gralise,  Neurontin),  a  medication  used  to  treat 
neuropathic  pain  and  epileptic  seizures,  has  been 
found  to  reduce  withdrawal  symptoms  and  the 


Sample  size  of  39. 
'  Specifically,  those  with  the  L/L  genotype  of  the 
5HTTLPR  polymorphism.  "L"  signifies  long  alleles 
and  "S"  signifies  short  alleles.  Possible  genotypes 
are  L/L,  S/S  and  S/L. 


use  of  marijuana  in  patients  with  addiction 
involving  cannabis.133 

Reward  Reduction  Medications.  Certain 
medications  work  to  reduce  the  rewarding  or 
pleasurable  effects  of  addictive  substances,  over 
time  decreasing  their  appeal. 

Disulfiram  (brand  name  Antabuse),  approved  by 
the  FDA  in  1949  to  treat  addiction  involving 
alcohol,  works  by  producing  unpleasant 
physiological  effects  in  individuals  who 
consume  alcohol;  these  aversive  reactions  serve 
as  a  deterrent  to  alcohol  consumption  among 
those  with  addiction  involving  alcohol*  134 

For  addiction  involving  alcohol,  disulfiram 
blocks  the  production  of  the  enzyme  aldehyde 
dehydrogenase  which  enables  the  liver  to 
metabolize  alcohol.135  The  obstruction  of  this 
process  leads  to  a  build  up  of  acetaldehyde§  in 
the  system,  causing  hangover-like  symptoms- 
nausea,  vomiting,  flushing,  rapid  heart  rate- 
shortly  after  alcohol  consumption.136  The 
medication  has  not  been  found  to  reduce 
cravings;  its  preventive  qualities  come  from 
replacing  the  pleasurable  effects  of  alcohol  with 
unpleasant  effects.137 

Although  disulfiram  is  one  of  the  oldest 
pharmaceutical  treatments  for  addiction 
involving  alcohol,  there  are  few  scientifically 
valid  studies  of  its  efficacy.138  The  medication 
appears  to  be  most  effective  when  its  use  is 
supervised  to  assure  compliance.139  Researchers 
suggest  that  the  relatively  limited  evidence  of 
the  efficacy  of  the  drug  may  be  linked  to  low 
adherence  rates:  in  one  study  only  20  percent  of 
participants  who  completed  the  trial  complied 
with  disulfiram  treatment.  Among  patients  who 
completed  the  trial,  those  who  received  a 


*  Disulfiram  is  the  most  commonly-used  aversion 
medication  for  the  treatment  of  addiction  involving 
alcohol.  Another  example  of  a  medication  that 
produces  a  similar  aversive  effect  in  individuals  who 
consume  alcohol  is  calcium  carbimide  (brand  name 
Temposil);  other  medications  used  for  non-addiction 
clinical  purposes,  such  as  cephalosporins  which  are 
used  to  treat  bacterial  infections,  have  side  effects 
similar  to  disulfiram  when  alcohol  is  consumed. 
§  The  major  metabolite  of  ethanol. 


-96- 


standard  dose  of  disulfiram  reported 
significantly  fewer  drinking  days  than  their 
peers  over  the  course  of  a  year.140  One 
explanation  for  the  variation  in  effectiveness 
may  be  related  to  addiction  severity:  those  with 
more  severe  addiction  may  drink  despite  the 
adverse  reactions  caused  by  disulfiram,  or  avoid 
taking  the  medication  altogether.141 

Naltrexone,  used  in  the  treatment  of  addiction 
involving  alcohol  and  opioids,  blocks  opioid 
receptors  in  the  brain,  leading  to  reductions  in 
the  reinforcing  effects  of  these  drugs.142  It  does 
this  by  disrupting  the  transmission  of  dopamine  - 
-and  thus  the  endorphin  rush-caused  by  alcohol 
and  opioid  ingestion.143 

Oral  naltrexone  (brand  names  Re  Via  and 
Depade),  which  is  available  as  a  daily  tablet, 
was  approved  by  the  FDA  to  treat  addiction 
involving  alcohol  in  1984.  Injectable  naltrexone 
(brand  name  Vivitrol),  which  is  an  extended 
release  monthly  deep  intramuscular  gluteal 
injection,*  144  was  approved  by  the  FDA  in  2006 
for  addiction  involving  alcohol  and  in  20 1 0  for 
the  treatment  of  addiction  involving  opioids.145 
Naltrexone  is  prescribed  for  patients  who  have 
not  ingested  opioids  for  seven  to  1 0  days 
because  it  can  cause  serious  withdrawal 
symptoms  if  used  at  the  same  time  as  an 
opioid.146 

Because  of  naltrexone's  mechanism  of  action — 
reducing  the  reward  or  "high"  associated  with 
substance  use—  some  patients  may  not  take  the 
medication  regularly. 147  Noncompliance  also 
may  be  associated  with  experiencing 
uncomfortable  side  effects '  at  the  start  of  a 
course  of  treatment. 148  Unless  participants 
adhere  to  their  treatment  regimen  70  to  90 
percent  of  the  time,1  naltrexone  does  not 
produce  significant  outcomes.149  Injectable 


When  injected,  the  pharmacological  agent  releases 
its  active  compound  in  a  consistent  way  over  a  long 
period  of  time. 

1  Side  effects  can  include  gastrointestinal  problems 
such  as  nausea,  vomiting  and  abdominal  pain  and 
central  nervous  system-related  symptoms  such  as 
headache  and  fatigue. 

*  The  necessary  adherence  rate  varies  by  the  duration 
of  treatment. 


naltrexone  provides  two  advantages  which  may 
improve  retention  and  success  rates:  the  need 
for  a  monthly  injection  rather  than  a  daily  pill 
and  the  need  for  regular  contact  with  medical 
and  other  supporting  staff  in  the  course  of  a 
clinic  visit  which  is  required  to  obtain  the 
medication.150  A  disadvantage  of  the  injection 
formulation,  however,  is  that  it  has  more  side 
effects  at  higher  doses.151 

For  addiction  involving  alcohol,  the  medication 
is  more  effective  at  reducing  heavy  drinking 
than  increasing  abstinence  rates.152  Several 
randomized,  placebo-controlled  trials  found  that 
compared  to  patients  taking  placebos,  patients 
taking  naltrexone  report  significantly  fewer 
drinking  days,  fewer  drinks  per  drinking  day, 
reduced  cravings  and  reduced  relapse.153 

Because  naltrexone  blocks  the  euphoric  effects 
of  opioids  and  does  not  produce  a  high  when 
taken,  there  is  much  less  potential  for  misuse  or 
diversion  than  there  is  for  other  pharmaceutical 
treatments,  such  as  methadone,  for  addiction 
involving  opioids.154  In  one  randomized, 
controlled  study,  patients  with  addiction 
involving  heroin  who  received  naltrexone 
injections  were  significantly  likelier  to  have 
remained  in  treatment  over  the  course  of  the 
study  than  patients  receiving  a  placebo 
injection.8  155  Buprenorphine,**  when  added  to 
naltrexone,  has  been  found  to  improve  retention 
in  treatment.156  Relapsing  to  the  use  of  opioids 
after  beginning  naltrexone  treatment  can 
increase  patients'  risk  of  overdosing,  due  to 
naltrexone's  effect  on  increasing  the  sensitivity 
of  opioid  receptors  in  the  brain  to  the  effects  of 
opioids.157 

Varenicline  (brand  name  Chantix)  is  an  effective 
therapy  for  smoking  cessation  that  works  by 
reducing  the  rewarding  effects  of  nicotine 
among  patients  who  smoke  while  on  the 
medication  and  by  reducing  the  craving  and 
withdrawal  symptoms  that  occur  among 
abstinent  patients.158 


s  Naltrexone  patients  also  were  less  likely  than 
placebo  patients  to  test  positive  for  cocaine, 
benzodiazepine,  marijuana  and  amphetamine  use. 
**  See  page  101. 


-97- 


Research  indicates  that  varenicline  use, 
compared  with  a  placebo,  can  significantly 
increase  a  patient's  chances  of  attaining 
continual  abstinence  from  smoking  over  six 
months.159  A  large-scale  analysis  of  several 
randomized  controlled  trials  found  that  the 
medication  was  significantly  more  effective  than 
placebos  or  bupropion  in  relieving  cravings  and 
in  increasing  the  likelihood  of  achieving 
continuous  abstinence  over  a  12-month 


While  nausea  is  the  most  commonly-reported 
side  effect,  insomnia,  headaches  and  nightmares 
also  are  prevalent.161  In  February  2008—  two 
years  after  Chantix  was  approved-the  FDA 
released  a  public  health  advisory  warning 
patients  that  the  medication  has  the  potential  to 
aggravate  psychiatric  illnesses  and  in  some  cases 
lead  to  the  development  of  neuropsychiatric 
symptoms,  such  as  anxiety,  tension,  depression 
or  suicide  attempts.162  This  advisory  led  to 
modifications  in  the  product  labeling  and  the 
medication  guide  advising  medical  professionals 
to  monitor  all  patients  taking  the  medication  for 
neuropsychiatric  symptoms.163  More  recently, 
medical  professionals  were  advised  to  monitor 
use  of  the  medication  among  patients  with 
cardiovascular  disease  since  Chantix  has  been 
linked  to  adverse  cardiovascular  effects  in  these 
patients.164 

Modafinil,  a  stimulant  medication  (brand  names 
Provigil,  Alertec  and  Modavigil),  used  to  treat 
narcolepsy  and  other  sleep  disorders,  reduces  the 
stimulating  effects  of  cocaine.165  At  the  same 
time,  it  may  reduce  cocaine  cravings  and 
withdrawal  symptoms.166  In  one  study,  patients* 
with  addiction  involving  cocaine  who  received 
daily  doses  of  modafinil  for  eight  weeks 
submitted  nearly  twice  as  many  clean  urine 
samples  than  placebo  patients  during  the  course 
of  the  study  and  were  more  than  twice  as  likely 
to  achieve  at  least  three  weeks  of  prolonged 
abstinence.167  Another  study  found  modafinil  to 
be  effective  in  reducing  cocaine  use  and  cocaine 
craving  in  patients  with  addiction  involving 


Who  met  clinical  diagnostic  criteria  for  dependence 
and  who  used  at  least  $200  worth  of  cocaine  during 
the  prior  month. 


cocaine  who  took  part  in  individual 
psychosocial  therapy.168 

Topiramate  (brand  name  Topamax),  an 
anticonvulsant,  has  been  validated  by 
randomized  controlled  trials  to  treat  addiction 
involving  alcohol.169  It  is  believed  to  work  by 
reducing  the  release  of  dopamine  and  thus  the 
rewarding  effects  of  alcohol  use  and  the  urge  to 
drink.170  It  appears  to  reduce  alcohol  withdrawal 
symptoms  and  can  be  used  in  patients  who  are 
not  yet  abstinent  from  alcohol.171  Topiramate 
also  is  a  promising  pharmaceutical  treatment  for 
addiction  involving  cocaine,  but  additional 
research  is  needed  to  establish  its  efficacy.172 
Preliminary  research  suggests  that  the 
anticonvulsant  and  mood-stabilizing  medications 
carbamazepine  and  valproate  also  may  be 
effective  in  treating  addiction  involving 
alcohol.173 

Vaccines.  Recent  research  in  pharmacotherapy 
for  substance  addiction  has  examined  the  use  of 
vaccines  in  the  treatment  process.174  These 
vaccines  work  by  producing  a  sufficient  quantity 
of  antibodies  that  bind  to  the  substance  and 
prevent  or  significantly  impede  it  from  entering 
the  brain,*  reducing  the  accumulation  of  the 
substance  in  the  brain  and  ultimately  decreasing 
its  rewarding  effects.175  Much  of  the  work  on 
vaccines  for  addiction  is  still  in  the  preclinical 
phase  of  development.176 

Vaccines  for  addiction  involving  nicotine5  are 
farthest  along  in  the  development  phase.  They 
are  proving  to  be  safe,  with  limited  adverse  side 
effects  and  have  shown  promise  for  helping 
smokers  quit.177  However,  these  vaccines  still 
are  undergoing  clinical  trials  to  test  for  safety 
and  efficacy.  While  they  may  be  helpful  in 
reducing  the  rewarding  effects  of  nicotine  in 
those  who  already  are  addicted,  they  do  not 


1  Who  did  not  have  co-occurring  addiction  involving 
alcohol. 

*  Antibodies  typically  are  comprised  of  larger 

molecules  than  addictive  substances,  making  them 

less  able  to  cross  into  the  brain. 

§  NicVax,  Nic002  (also  known  as  NicotineQB)  and 

TA-Nic  are  the  vaccines  currently  under 

investigation. 


-98- 


prevent  addiction  and  should  be  used  in 
conjunction  with  other  therapeutic 
approaches.178 

A  cocaine  vaccine  also  has  been  developed  and 
was  found  in  a  preliminary  study  to  reduce 
cocaine  use.179  Researchers  also  are  exploring  a 
vaccine  or  antibody  administrations  for  other 
addictive  stimulants  including 
methamphetamine180  and  phencyclidine  (PCP)181 
and  have  found  promising  results  in  animal 
samples. 

Maintenance  Medications/Medication 
Assisted  Therapies.  Certain  medications  used 
to  treat  addiction  function  by  delivering  a  less 
dangerous  or  less  addicting  version  of  the 
addictive  substance  during  the  acute  care  phase 
of  addiction  treatment.   These  medications  may 
function  by  reducing  cravings  or  withdrawal 
symptoms  and/or  by  reducing  the  rewards 
associated  with  the  addictive  substance. 
Maintenance  medications  have  proven  to  be 
highly  effective  in  treating  a  variety  of 
manifestations  of  addiction  and  in  disease 
management. 

Nicotine  Replacement  Therapy  (NRT).  NRT, 
when  used  as  directed,  provides  lower  doses  of 
nicotine  at  a  slower  rate  than  smoking,182 
thereby  easing  nicotine  withdrawal  symptoms.183 
For  many  smokers,  it  works  best  as  an  aid  to 
managing  nicotine-related  cravings  when  used  in 
conjunction  with  psychosocial  therapies.  In 
most  cases  of  acute  care  treatment,  a  therapeutic 
level  of  nicotine  is  reached  and  then  use  is 
reduced  in  order  to  eliminate  the  medication 
entirely  or  reach  a  maintenance  level.184 
Because  most  patients  who  use  NRT  control 
their  treatment  regimen  on  their  own,  there  is  a 
risk  that  the  nicotine  intake  from  NRT  products 
may  be  higher  than  intended  for  those  who  do 
not  use  them  as  directed  or  who  use  them  while 
continuing  to  smoke.185 

Nicotine  gum,  lozenges  and  inhalers  and  nasal 
sprays  deposit  nicotine  in  the  bloodstream 
through  the  lining  of  the  mouth  or  nose,  whereas 


These  medications  also  may  be  used  for  an 
extended  period  of  time  for  disease  management. 


the  nicotine  patch  delivers  the  nicotine  through 
the  skin.186  Nicotine  gum  and  lozenges  both  are 
over-the-counter  medications;  inhalers  and 
sprays  require  prescriptions.  The  nicotine  patch 
is  available  both  over-the-counter  and  by 
prescription. 

A  meta-analysis f  of  1 3  studies  found  that  use  of 
nicotine  gum  can  increase  significantly  smokers' 
chances  of  quitting  for  at  least  six  months.188 
The  use  of  nicotine  lozenges  nearly  doubles  the 
chance  of  achieving  continuous  abstinence  over 
at  least  a  six-month  period.189  Side  effects  of 
nicotine  gum  and  lozenges  include  sore  throat, 
heartburn,  jaw  pain  and  nausea.190 

Nicotine  inhalers  come  in  cartridges  which 
release  nicotine  vapor  when  puffed  that  is 
absorbed  through  the  lining  of  the  mouth  and 
through  the  back  of  the  throat.191  Two  meta- 
analyses found  that  inhaler  use  can  nearly 
double  patients'  abstinence  rate  over  at  least  a 
six-month  period,  relative  to  those  who  received 
a  placebo.192  The  primary  side  effect  is  local 
irritation.193  Nicotine  nasal  spray  is  aerosolized 
nicotine  that  comes  in  a  spray  pump.  The 
nicotine  is  sprayed  into  the  nostrils  and  absorbed 
rapidly  by  the  nasal  membranes.194  Meta- 
analyses indicate  that  patients  almost  double 
their  chances  of  achieving  and  maintaining 
abstinence  at  six  months  with  the  use  of  a  nasal 
spray  versus  a  placebo.195  The  primary  side 
effect  of  the  medication  is  local  irritation.196 
This  form  of  NRT  has  the  highest  potential  for 
misuse:  15  to  20  percent  of  patients  report  using 
the  spray  for  longer  than  the  recommended 
period  and  five  percent  report  using  a  higher 
dose  than  recommended.197 

The  nicotine  patch  is  available  in  both  single  and 
step-down  dosages.  An  eight-week  course  of 


'  The  review  included  only  those  studies  that  had 
been  published  in  peer-reviewed  journals;  however, 
some  studies  were  supported  by  the  pharmaceutical 
industry.  Most  of  the  studies  included  in  the  analysis 
drew  participants  from  self-selecting  populations  of 
smokers  and,  in  general,  the  studies'  participants 
received  counseling  regardless  of  whether  they  were 
randomly  assigned  to  receive  medication  or  placebos. 
(This  is  true  of  all  meta-analyses  of  tobacco  cessation 
interventions  reported  here.) 


-99- 


treatment  is  most  common;     however,  one 
study  found  that  an  extended  course  of 
treatment-24  weeks-improves  outcomes.199 
Unlike  other  forms  of  NRT,  patches  do  not 
address  the  behavior  of  smoking  by  occupying 
the  hands  or  the  mouth  or  inhaling,  but  by 
passively  and  slowly  delivering  the  nicotine.200 
A  meta-analysis  of  24  studies  found  that  the  use 
of  nicotine  patches  for  six  to  14  weeks  can 
nearly  double  a  smoker's  chance  of  sustaining 
abstinence  for  at  least  six  months  compared  to 
placebos.201  Unlike  nicotine  gum,  there  is  little 
evidence  supporting  a  connection  between 
higher  doses  and  higher  efficacy  rates,  or 
between  longer  treatments  and  better 
outcomes.202  The  patch  also  appears  to  be 
effective  regardless  of  additional  psychosocial 
interventions.203  The  primary  side  effect  of  the 
patch  is  skin  sensitivity  and  irritation.204 

Contrary  to  the  many  controlled  studies 
supporting  the  efficacy  of  NRT,  a  population- 
based  survey  of  adult  smokers  who  recently  had 
quit  smoking  casts  doubt  on  its  effectiveness  in 
smoking  cessation  and  relapse  prevention.  In 
this  study,  nearly  one-third  (30.6  percent)  of 
smokers  who  had  quit  smoking  within  the 
previous  two  years  reported  having  relapsed, 
regardless  of  whether  they  used  NRT  for  the 
recommended  amount  of  time  and  regardless  of 
whether  the  use  of  NRT  was  accompanied  by 
professional  behavioral  counseling.  While  this 
study  appears  to  call  into  question  the  efficacy 
of  NRT  in  achieving  smoking  cessation  in  the 
general  population,205  it  actually  underscores  the 
fact  that  NRT  is  not  a  comprehensive  treatment 
approach  to  addiction  involving  nicotine,  but 
rather  an  aid  to  smoking  cessation  to  be  used  in 
conjunction  with  other  evidence-based  acute 
care  and  chronic  disease  management 
approaches. 

Methadone.  Methadone  is  a  synthetic  opioid 
used  as  replacement  therapy  for  patients  with 
addiction  involving  opioids.  Methadone 
reduces  cravings  and  withdrawal  symptoms  by 


Methadone  can  be  used  in  the  stabilization,  acute 
treatment  and  disease  management/maintenance 
phases  of  treatment  for  patients  with  addiction 
involving  opioids. 


stimulating  opioid  receptors  in  the  brain  and 
reduces  the  rewarding  effects  of  opioids  by 
blocking  their  euphoric  effects.207  Although 
methadone  is  an  opioid,  it  does  not  produce  the 
same  euphoric  rush  characteristic  of  heroin  or 
oxycodone;  its  effects  are  slower  and  steadier.208 

Methadone  can  be  taken  orally  and  has  a  long 
half-life  with  a  slow  onset  of  action.209 
Methadone  is  safe  when  used  as  directed.  It 
allows  individuals  with  addiction  involving 
opioids  to  function  relatively  normally.210 
Potential  side  effects  of  methadone  include 
drowsiness,  weakness,  headache  and  nausea,  and 
side  effects  are  more  likely  to  occur  when 
starting  methadone,  when  switching  from 
another  narcotic/opioid  medication  to 
methadone  and  when  the  dosage  is  increased.211 

Multiple  studies  have  found  that  participation  in 
methadone  maintenance  treatment  (MMT)  is 
related  to  significant  reductions  in  patients'  use 
of  opioids,  criminal  behavior,  injection  drug  use, 
needle  sharing  and  risky  sexual  behavior  which 
can  increase  the  risk  of  HIV  and  sexually- 
transmitted  diseases;'  MMT  also  is  related  to 
higher  treatment  retention  rates.212 

Methadone  does,  however,  carry  the  potential 
for  misuse  213  and  the  risk  of  overdose.214  While 
methadone  is  effective  in  inhibiting  the  effects 
of  opioids  like  heroin  and  morphine,  it  does  not 
appear  to  inhibit  the  effects  of  alcohol  or  other 
drugs;  rather  methadone  may  magnify  the 
effects  of  alcohol  and  other  CNS  depressants.215 
Its  use  in  concert  with  other  addictive  substances 
can  result  in  adverse  interactions.  Methadone 
also  may  accumulate  in  the  body  to  a  toxic  level 
if  it  is  taken  too  often,  or  in  larger  than 
recommended  quantities.216  Because  of  the  risk 
of  methadone  misuse  and  its  consequences, 
methadone  distribution  is  regulated  by  strict 
federal  and  state  guidelines.217  Methadone 
prescribed  for  addiction  involving  opioids  can 


1  Because  methadone  does  not  require  intravenous 
injection,  methadone  users  are  less  likely  to  engage  in 
needle  sharing  and  because  they  do  not  need  the  same 
amount  of  money  to  obtain  heroin,  they  are  less 
likely  to  engage  in  prostitution  compared  to  their 
heroin-using  counterparts. 


-100- 


be  obtained  only  through  specially-licensed 

*  218 

treatment  programs. 

Buprenorphine.  Buprenorphine  is  used  in  the 
treatment  of  addiction  involving  opioids  and, 
when  used  as  directed,  functions  both  by 
reducing  craving  for  addictive  opioids  and  by 
easing  withdrawal  symptoms.219  At  low  doses, 
buprenorphine  enables  patients  with  addiction 
involving  opioids  to  discontinue  their  use  of  the 
drugs  without  experiencing  withdrawal 

220 

symptoms. 

There  are  two  forms  of  the  medication: 
buprenorphine  alone  (brand  name  Subutex)  and 
a  buprenorphine/naloxone  combination  therapy 
(brand  name  Suboxone).221  Approved  in  2002 
by  the  FDA  for  treating  addiction  involving 
opioids,  Subutex  generally  is  prescribed  during 
acute  treatment  followed  by  Suboxone  for 
maintenance  therapy.222  The  naloxone 
component  of  Suboxone  serves  to  reduce  the 
rewarding  effects  of  opioids  and  helps  to  prevent 
the  misuse  of  the  medication  which  can  occur  if 
Suboxone  is  crushed  and  then  injected  or  snorted 
to  achieve  a  high.223 

Buprenorphine  must  be  administered  under  the 
supervision  of  a  trained  physician.224  It  can  be 
prescribed  by  physicians  who  are  certified  in 
addiction  medicine '  or  who  complete  at  least 
eight  hours  of  training1'  in  the  treatment  and 
management  of  addiction  involving  opioids.5  225 
Once  such  training  is  completed,  physicians  may 
submit  an  application  to  the  Substance  Abuse 
and  Mental  Health  Services  Administration 
(SAMHSA)  and  receive  an  identification 


Such  restrictions  apply  only  to  the  use  of  methadone 
in  addiction  treatment  and  not  when  physicians 
prescribe  methadone  to  treat  or  manage  pain. 
'  Through  the  American  Board  of  Addiction 
Medicine  or  the  American  Osteopathic  Association. 
*  Approved  training  includes  training  provided  by  the 
American  Society  of  Addiction  Medicine,  the 
American  Academy  of  Addiction  Psychiatry,  the 
American  Medical  Association,  the  American 
Osteopathic  Association,  the  American  Psychiatric 
Association  or  any  other  organization  that  the 
Secretary  of  Health  determines  is  appropriate. 
§  Physicians  also  must  have  the  ability  to  provide  or 
refer  patients  to  any  necessary  ancillary  services. 


number  from  the  DEA  allowing  them  to 
prescribe  the  medication.226 

Buprenorphine  provides  moderate  relief  from 
opioid  withdrawal  and  has  less  risk  of  misuse 
and  overdose  than  methadone.227  Another 
advantage  to  buprenorphine  is  that  it  can  be 
dosed  less  frequently  than  every  day  and  still 
have  a  beneficial  effect,  which  could  help  to 
enhance  medication  adherence.228  Promising 
results  are  emerging  from  preliminary  research 
on  low-frequency  dosing  with  sustained-release 
formulations  of  the  medication.229  Despite  these 
advantages,  buprenorphine  has  similar  side 
effects  to  methadone  and  other  opioids  including 
nausea,  vomiting  and  constipation.230 

Buprenorphine  is  equally  effective  as  methadone 
in  treating  addiction  involving  opioids.231 
Research  reviews  of  pharmaceutical  treatments 
for  addiction  involving  opioids  have  found  that 
regardless  of  the  dose,  buprenorphine  is  better 
than  placebos  for  ensuring  patient  retention,232 
and  that  higher  doses  increase  the  likelihood  of 
retention  and  abstinence  relative  to  lower 
doses.233  A  randomized,  controlled  trial  found 
that  patients  receiving  buprenorphine  were 
significantly  likelier  to  have  negative  urinalyses 
than  placebo  patients  and  to  report  decreased 
cravings  for  opioid  drugs.234 

Recent  research  has  begun  to  explore,  using 
animal  models,  the  benefits  of  using 
buprenorphine  to  treat  addiction  involving 
methamphetamine.235 

Oral  THC.  Preliminary  research  suggests  that 
oral  tetrahydrocannabinol  (THC),  made  from  the 
psychoactive  ingredient  contained  in  cannabis, 
may  serve  to  reduce  withdrawal  symptoms  and 
cravings  in  patients  with  addiction  involving 
marijuana  without  producing  marijuana-like 
intoxication  effects.236  However,  research  on 
oral  THC  and  other  pharmaceutical  therapies  for 
use  in  the  treatment  of  patients  with  addiction 
involving  marijuana,  while  promising,  is  in  an 
early  stage  and  clinical  trials  are  needed  to 
support  their  use  in  clinical  interventions.237 


-101- 


Psychosocial  Therapies 

Psychosocial  treatments  for  substance  addiction 
aim  to  alter  patients'  attitudes  and  behaviors 
with  regards  to  the  use  of  tobacco,  alcohol  and 
other  drugs.  These  therapies  enhance  patients' 
skills  in  coping  with  life  challenges,  navigating 
high-risk  situations,  avoiding  substance  use 
triggers,  controlling  cravings  and  coping  with 
lapses.238  Some  therapies  focus  on  enhancing 
patients'  motivations  to  change  their  substance- 
related  behaviors.  Other  therapies  focus  on 
helping  patients  alter  their  environments  in  order 
to  reduce  pressures  and  cues  to  use,  or  provide 
positive  or  negative  reinforcements  to  help 
patients  change  their  attitudes  and  behavior.239 

Psychosocial  therapies  are  critical  components 
of  almost  every  treatment  regimen,  regardless  of 
a  patient's  primary  substance  of  addiction;  when 
combined  with  pharmaceutical  treatments  they 
enhance  treatment  efficacy.240 

As  is  true  of  treatments  for  most  other  health 
conditions,  successful  treatment  for  patients  with 
addiction  takes  into  account  patients'  social  and 
financial  circumstances  as  well  as  their  physical 
well-being.  And,  as  is  the  case  for  other  health 
conditions,  not  all  approaches  work  equally  well 
for  all  patients;  the  effectiveness  of  a  particular 
approach  depends  on  patient  circumstances  such 
as  the  severity  of  the  addiction,  the  primary 
substance  involved  in  the  addiction,  the  extent  of 
social  support  and  the  presence  of  co-occurring 
disorders;  the  venue  in  which  the  treatment  is 
provided;  and  the  nature  and  dynamics  of  the 
provider-patient  relationship.241 

The  following  are  brief  descriptions  of  the 
primary  psychosocial  therapies  for  addiction 
treatment: 

Motivational  Interviewing  (MI)  and 
Motivational-Enhancement  Therapy  (MET). 

Motivational  techniques  capitalize  on  patients' 
readiness  to  stop  using  addictive  substances  and 
enter  treatment  by  bolstering  their  motivation  to 
change  their  substance  use  behaviors.242  In 
acute  care,  motivational  therapies  are  employed 
early  in  the  treatment  process.  They  also  may  be 


used  in  conjunction  with  other  psychosocial  and 
pharmaceutical  approaches.243 

Motivational  Interviewing  (MI),  which  can 
occur  in  inpatient  or  outpatient  settings,  is  rooted 
in  the  idea  that  individuals  with  addiction  often 
feel  ambivalent  about  their  substance  use  and  the 
need  to  change  their  behaviors.244  MI 
techniques  help  patients  deal  with  this 
ambivalence  and  strengthen  their  commitment  to 
engage  in  behavior  change.245  Motivational 
Enhancement  Therapy  (MET)  is  an  adaptation 
of  MI*  that  restricts  the  intervention  to  four 
sessions.1 246 

Both  MI  and  MET  have  proven  efficacy  in 
addressing  adolescent  and  adult  addiction  and 
are  cost-effective  approaches  to  treating 
addiction  involving  nicotine,  alcohol  and  other 
drugs.247  Two  main  benefits  of  MI/MET  are 
increased  treatment  retention  and  program 
completion,248  which  are  associated  with 
improved  treatment  outcomes.249  A  study  of 
tobacco  cessation  among  patients  who  had 
previously  had  a  heart  attack  found  that  those 
receiving  MI  were  more  likely  to  achieve 
abstinence  after  a  year  than  patients  who  only 
received  brief  advice  about  quitting  (65.5 
percent  vs.  37.0  percent).1  250  An  evaluation  of 
MET  across  five  treatment  sites  found  that  it 
was  associated  with  greater  reductions  in  alcohol 
and  other  drug  use  over  a  12-week  period  than 
standard  individual  counseling.5  251 


Both  modalities  are  based  on  the  Transtheoretical 
Model  of  Behavior  Change. 

1  MET  was  developed  for  Project  MATCH  (1997),  a 
large  study  of  treatment  efficacy  that  compared  the 
effectiveness  of  three  treatment  modalities:  12 
sessions  of  cognitive  behavioral  therapy  (CBT),  12 
sessions  of  Twelve-Step  Facilitation  Therapy  or  four 
sessions  of  MET.  All  three  groups  showed 
significant  and  comparable  declines  in  alcohol  use  up 
to  three  years  later. 

*  These  rates  are  based  on  at  least  one  week  of 
abstinence  corroborated  by  a  family  member. 
§  More  than  450  individuals  with  addiction  were 
randomly  assigned  to  receive  three  sessions  either  of 
MET  or  standard  individual  counseling  during  a  one- 
month  period. 


-102- 


Motivational  Interviewing 

The  MI  therapist  attempts  to: 

FvnrpQQ  pmnntViv  tlirmio'li  rpflpptivp 

i^AJJltoo  K^lLi^jalLly   llllVJllgll  1 1  lltVll  V  t 

listening; 

• 

Recoonize  discrenancies  between  natients' 

goals  or  values  and  their  current  substance 

use; 

• 

Provide  normative  feedback  on  the 

discrepancy  between  patients'  substance 

use  and  that  of  their  peers; 

• 

Adjust  to  patient  resistance  rather  than 

oppose  it  directly; 

• 

Avoid  arguments  and  direct 

confrontations;  and 

• 

Support  patients'  sense  of  self-efficacy  to 

change  their  behavior.252 

Cognitive  Behavioral  Therapy  (CBT). 

Cognitive  Behavioral  Therapy  (CBT)  involves 
training  in  social  skills,  self-control  and  stress 
management  through  activities  such  as  role 
playing,  behavioral  modeling  and  feedback.253  It 
is  designed  to  help  patients  identify,  recognize 
and  avoid  thought  processes,  behaviors  and 
situations  that  are  associated  with  substance  use; 
manage  cravings;  refuse  offers  of  tobacco, 
alcohol  or  other  drugs;  and  develop  better 
problem-solving  and  coping  skills.254 

CBT  generally  is  used  as  a  short-term 
intervention  and  can  be  tailored  both  to  inpatient 
and  outpatient  programs  via  group  or  individual 
therapy.255  The  therapy  has  been  proven 
effective  for  adolescents  and  adults  and  for  a 
variety  of  manifestations  of  substance 
addiction.256  CBT  has  demonstrated  efficacy  for 
specific  populations  such  as  women  with 
addiction  and  individuals  with  co-occurring 
disorders.* 257 

Community  Reinforcement  Approach  (CRA). 

The  Community  Reinforcement  Approach 
(CRA)  is  a  multi-phase,  intensive  24-week 
outpatient  treatment  for  addiction  involving 


CBT  may  work  as  well  for  other  populations  and 
other  substances,  but  available  data  largely  are 
focused  on  the  ones  described  here. 


alcohol  and  drugs  other  than  nicotine. 
Counseling  sessions  focus  on  improving  family 
relations,  learning  skills  to  reduce  substance  use, 
acquiring  vocational  skills  and  developing 
recreational  activities  and  social  networks  that 
can  help  to  minimize  the  drive  to  engage  in 
substance  use.259  CRA  also  assists  patients  in 
developing  communication,  problem-solving 
and  drug  refusal  skills.260  CRA  is  based  on  the 
notion  that  patients  must  be  taught  life  skills  and 
shown  that  living  substance  free  can  be  more 
rewarding  than  a  life  of  addiction.261 

There  is  evidence  of  the  effectiveness  of  CRA 
for  treating  patients  with  addiction  involving 
alcohol  and  drugs  other  than  nicotine.262 
Effectiveness  is  enhanced  when  coupled  with 
pharmaceutical  interventions  and  abstinence- 
based  incentive  programs,  such  as  the  provision 
of  vouchers  exchangeable  for  retail  items 
contingent  on  negative  urinalysis  results.263 
Participation  in  a  CRA  intervention  also  has 
shown  positive  supplementary  effects,  such  as 
increased  employment  rates  and  decreased 
criminal  involvement.264 

Contingency  Management  (CM). 

Contingency  Management  (CM)  is  an 
intervention  that  uses  positive  and  negative 
reinforcement  to  alter  behavior,  although 
rewarding  positive  behavior  has  been 
demonstrated  to  be  more  effective  than 
punishing  negative  behavior.265  Most  CM 
interventions  provide  patients  with  vouchers  and 
incentives  for  meeting  treatment-related  goals 
such  as  producing  a  drug- free  urine  test. 
Incentives  can  include  cash  rewards,  vouchers  to 
purchase  desired  items  or  treatment-related 
privileges  such  as  receiving  multiple  doses  of 
medication  at  one  time  to  avoid  having  to  make 
numerous  clinic  visits.266 

The  effectiveness  of  CM  has  been  demonstrated 
for  addiction  involving  nicotine,  alcohol, 
marijuana,  cocaine,  methamphetamine  and 
opioids.267  CM  can  improve  program  retention,' 
increase  abstinence  and  help  prevent  relapse.  It 
is  most  successful  when  used  in  conjunction 


1  Improved  program  retention  is  associated  with  other 
positive  treatment  outcomes. 


-103- 


with  other  interventions,  such  as  the  community 
reinforcement  approach  (CRA).* 268 

Behavioral  Couples/Family  Therapy. 

Couples-  and  family-based  treatments  aim  to 
improve  communication  and  support  and  reduce 
conflict  between  couples  and  within  families 
that  have  a  member  with  addiction.269  Since 
lack  of  social  and  family  support  often  is  a 
barrier  to  treatment  enrollment,  the  support  of 
family  members  is  important  in  helping 
individuals  with  addiction  enter  and  complete 
treatment.  Studies  have  found  family  and 
couples  therapy  to  be  effective  for  adolescents 
and  adults,  men  and  women  and  racial/ethnic 
minorities  as  well  as  for  individuals  for  whom 
the  primary  substances  of  addiction  are  alcohol, 
marijuana,  opioids  or  cocaine.270 

A  family  approach  to  treatment  generally  is 
more  effective  than  individual-based  programs 
and  tends  to  have  higher  retention  rates  than 
other  evidence-based  interventions.271 
Combining  couples/family  therapy  with  other 
forms  of  individual-based  treatments,  such  as 
cognitive  behavioral  therapy  (CBT),  tends  to 
increase  treatment  effectiveness.272 


[Addiction]  is  a  family  disease  and  you  cannot 
treat  an  addict  without  bringing  in  the  family 
and  children.215 

-John  Schwarzlose 
Chief  Executive  Officer 
Betty  Ford  Center 


Combined  Therapies 

Treatment  programs  that  combine 
pharmaceutical  and  psychosocial  treatments 
typically  are  more  effective  for  individuals  with 
addiction  than  the  use  of  either  form  of 
intervention  alone.273 


Stronger  effects  were  found  when  the  voucher  was 
delivered  immediately  after  the  patient  met  the 
contingency  requirement  and  when  vouchers  were  of 
a  higher  value. 


Our  efforts  to  date  have  taught  us  some 
humbling  lessons  about  addictive  diseases, 
namely,  that  they  are  complex  biopsychosocial 
entities  which  defy  simple  "either/or" 
solutions.214 

-Norman  S.  Miller,  MD 
Professor  of  Medicine  and  Psychiatry 
Michigan  State  University 


Combination  therapy  is  successful  for  multiple 
reasons.  First,  the  provision  of  one  treatment 
modality  tends  to  enhance  compliance  with  the 
other.276  For  example,  medication  may  help 
patients  better  tolerate  withdrawal  symptoms 
that  otherwise  might  have  discouraged  their 
participation  in  psychosocial  therapy  and 
psychosocial  therapy  might  encourage  patients 
to  initiate  and  maintain  a  course  of 
pharmaceutical  therapy.277  Medications  used  in 
conjunction  with  psychosocial  interventions 
have  been  found  to  increase  patients'  likelihood 
of  remaining  in  treatment  and  maintaining 
abstinence.278  Second,  because  there  is  no  one 
treatment  that  works  perfectly  for  every  patient, 
patients  who  are  provided  with  more  than  one 
treatment  approach  have  an  increased  chance  of 
success.279  Third,  each  modality  may  produce 
different  outcomes,  increasing  overall  success. 
For  instance,  in  the  case  of  smoking  cessation, 
pharmaceutical  therapy  helps  patients  face 
withdrawal  symptoms  and  maintain  abstinence, 
while  psychosocial  treatments  improve 
behavioral,  cognitive  and  coping  skills  that  are 
particularly  useful  for  ensuring  compliance  with 
treatment  and  preventing  relapse.280 

Addiction  Involving  Nicotine.  The 

combination  of  nicotine  replacement  therapy 
(NRT)  and  psychosocial  approaches  to  smoking 
cessation  increases  patients'  chances  of  quitting 
and  their  chances  of  achieving  long-term 
abstinence.281  A  review  of  combined  therapy 
studies  shows  that  the  inclusion  of  NRT 
produced  up  to  a  15-percentage  point  increase  in 
efficacy  rates  over  psychosocial  treatment 
alone.282  One  explanation  for  the  improved 
results  of  combined  therapies  for  tobacco 
cessation  is  that  NRT  is  the  primary  mechanism 
behind  patients'  initial  quitting  success  while  the 
psychosocial  therapies  give  patients  the  tools 


-104- 


they  need  to  avoid  relapse  over  the  longer 
term.283  Forms  of  pharmaceutical  therapy  other 
than  NRT,  such  as  antidepressants,  also  can 
enhance  the  benefits  of  psychosocial  treatment 
for  smoking  cessation.284 


Addiction  Involving  Alcohol.  In  one  study, 
patients  with  addiction  involving  alcohol  who 
received  daily  doses  of  naltrexone  were  less 
likely  than  those  taking  placebos  to  relapse  if 
they  also  participated  in  psychosocial  therapies, 
including  cognitive  behavioral  therapy  (CBT) 
(38  percent  vs.  60  percent)  or  motivational- 
enhancement  therapy  (MET)  (44  percent  vs.  56 
percent)  over  the  course  of  12  weeks.* 286 
Patients  in  another  study f  who  received  CBT  for 
a  three-month  period  were  likelier  to  achieve 
abstinence  by  the  end  of  the  12-week  program  if 
they  also  received  daily  doses  of  acamprosate 
(38  percent  vs.  14  percent).287  Another  study 
found  that  six  months  after  treatment 
completion,  disulfiram  patients  in  a  community 
reinforcement  approach  (CRA)  program  spent 
significantly  less  time  drinking  than  patients 
who  used  only  disulfiram  (abstinent  28.3  days 
vs.  8.0  days  that  month).288 


CBT  patients  who  took  naltrexone  spent 
significantly  more  of  their  time  in  treatment  abstinent 
from  alcohol  than  any  of  the  other  study  groups. 
'  The  study  groups  were  not  randomized  but  matched 
based  on  gender,  age,  previous  treatment  episodes, 
detoxification  history  and  average  alcohol  intake. 


Addiction  Involving  Other  Drugs.  With 
regard  to  treatment  for  addiction  involving 
opioids,  incorporating  family  therapy  into  a 
treatment  regimen  that  includes  naltrexone 
therapy  enhances  treatment  outcomes  with 
regard  to  medication  compliance;  abstinence 
from  opioids  and  other  drugs  during  treatment 
and  during  a  year  of  follow-up;  and  measures  of 
drug-related,  legal  and  family  problems  at  one- 
year  follow-up.289  A  meta-analysis  of  30  studies 
conducted  in  outpatient  methadone  treatment 
settings  found  that  the  inclusion  of  contingency 
management  (CM)  is  related  to  fewer  positive 
urine  tests  submitted  by  patients  with  addiction 
involving  opioids.290  CM  also  has  been  found  to 
augment  naltrexone  treatment  for  addiction 
involving  opioids  by  increasing  patients' 
compliance  with  their  treatment  regimen. 
Naltrexone  patients  who  received  contingency 
management  in  the  form  of  vouchers  in 
exchange  for  clean  urinalyses,  on  average, 
stayed  in  treatment  longer  (7.4  weeks  vs.  5.6 
weeks),  submitted  more  opioid- free  urine 
samples  (18.9  vs.  13.5)  and  were  abstinent 
continuously  over  longer  periods  of  time  (49.1 
days  vs.  37.7  days)  than  patients  who  received 
naltrexone  without  a  CM  component.291 
Another  study  found  that  patients  on  methadone 
maintenance  treatment  who  received  weekly 
community  reinforcement  approach  (CRA) 
sessions  demonstrated  significantly  greater 
reductions  in  drug  problem  severity1  than 
patients  who  received  standard  methadone 

292 

maintenance  services. 

Other  research  finds  that  cognitive  behavioral 
therapy  (CBT)  patients  who  received  daily 
doses§  of  modafmil  versus  a  placebo  provided 
significantly  more  clean  urine  tests  (42.3  percent 
vs.  24.0  percent)  and  were  likelier  to  achieve 
abstinence  from  cocaine  over  at  least  a  three- 
week  period  (33  percent  vs.  13  percent).293 

Addiction  Involving  Poly-Substances. 

Research  on  the  best  methods  of  treating 
individuals  with  addiction  involving  multiple 
substances  is  limited.  One  study  found  that 
methadone  maintenance  patients  with  addiction 


As  measured  by  the  Addiction  Severity  Index. 
400  mgs. 


A  Spectrum  of  Smoking  Cessation 
Treatments 

Smokers  of  less  than  five  cigarettes  per  day 
will  have  a  good  chance  of  success  in  quitting 
by  choosing  a  quit  date,  getting  rid  of  tobacco 
and  using  freely-available  counseling/support 
services.  Smokers  of  6-14  cigarettes  per  day 
probably  are  moderately  dependent  and  will 
benefit  from  an  approved  smoking  cessation 
aid  (nicotine  patch,  gum,  lozenge,  inhaler  or 
nasal  spray,  bupropion,  varenicline).  Smokers 
of  15  or  more  cigarettes  per  day  probably  are 
highly  dependent  and  will  benefit  from  more 
intensive  counseling  and  possibly  combination 
pharmaceutical  therapy.285 


-105- 


involving  both  opioids  and  cocaine  fared  better 
if  they  were  randomly  assigned  to  receive 
bupropion  versus  placebos  and  CM  versus  no 
psychosocial  intervention.294  Other  research 
points  to  the  potential  utility  of  combining  an 
antidepressant*  with  CM  for  patients  with 
addiction  involving  opioids  and  cocaine  who  are 
maintained  on  buprenorphine.295  Patients  who 
received  this  combined  therapy  provided  more 
drug-free  urine  samples  during  treatment  and 
achieved  a  period  of  continuous  abstinence  that 
was,  on  average,  twice  as  long  as  patients  with 
addiction  involving  opioids  and  cocaine  who 
were  in  the  control  conditions. f  296  Preliminary 
evidence  also  suggests  that  daily  doses  of 
naltrexone1  combined  with  CBT  may  be 
effective  for  treating  addiction  involving  alcohol 
and  cocaine,  particularly  among  men.297 

Nutrition  and  Exercise 

A  healthy  nutrition  and  exercise  regimen  can 
mitigate  the  symptoms  of  withdrawal,  enhance 
the  effects  of  evidence-based  treatment  and  help 
sustain  successful  treatment  outcomes.298 
Furthermore,  because  different  addictive 
behaviors  can  share  common  causes,  patients  in 
treatment  for  addiction  involving  nicotine, 
alcohol  or  other  drugs  may  substitute  unhealthy 
foods  in  an  attempt  to  satisfy  addictive 
cravings.299  This  is  particularly  evident  in  the 
common  case  of  weight  gain  following  smoking 
cessation.  As  such,  a  comprehensive  approach 
to  addiction  treatment  includes  interventions 
aimed  at  ensuring  good  nutrition  and  exercise. 

Nicotine,  alcohol  and  other  drug  use  also  disrupt 
normal  body  functioning— resulting  in  nutritional 
deficiencies,  dehydration  or  electrolyte 
imbalance-and  often  lead  to  unhealthy  lifestyle 
changes  such  as  poor  diet  and  irregular  eating 
habits.300  Providing  patients  in  addiction 
treatment  with  nutritional  programming  may 
help  them  to  reverse  some  of  the  damage  that 
smoking,  drinking  and  using  other  drugs  can 
inflict  on  their  bodies.  The  improvements  in 


desipramine 
'  Who  took  placebos  combined  with  CM, 
desipramine  without  CM  or  placebos  without  CM. 
*  150  mg. 


general  health  and  mood  that  may  result  from 
healthy  eating  habits  also  could  help  patients 
maintain  their  abstinence.301 

Some  individuals  in  treatment  attempt  to 
compensate  for  the  lack  of  alcohol,  for  example, 
by  consuming  significant  amounts  of  sugar  and 
other  carbohydrates  which  may  increase 
serotonin5  levels.302  A  healthier  approach, 
according  to  one  theory,  suggests  that  eating 
foods  that  are  rich  in  the  precursors  of  the 
neurotransmitters  which  are  depleted  when  a 
substance  user  abstains  will  reduce  cravings  for 
those  substances  and  facilitate  the  treatment 
process.303  These  include  protein-rich  foods 
such  as  meat,  fish,  dairy  products  and  nuts.304 

Exercise  also  stimulates  brain  cells  that  reinforce 
dopamine -related  reward  pathways.305  This 
reinforcement  may  allow  substance  users  to 
experience  pleasurable  effects  from  exercise 
which  potentially  could  reduce  their  substance- 
related  cravings.306  Exercise  generally  is 
beneficial  in  reducing  symptoms  of  depression 
and  anxiety  that  often  co-occur  with  and 
contribute  to  addiction.307  Another  theory 
regarding  the  utility  of  exercise  in  a 
comprehensive  treatment  program  is  that  as 
individuals  develop  a  mastery  of  exercise 
techniques,  they  increase  their  self-efficacy—the 
belief  that  one  can  master  new  skills— which  can 
be  applied  to  disease  management  strategies.308 
Patients  who  exercise  in  group  settings  also  may 
benefit  from  social  support  networks  and  social 
interactions  that  do  not  involve  tobacco,  alcohol 
or  other  drug  use.309 

Exercise  moderates  the  effects  of  nicotine 
withdrawal  symptoms  including  reductions  in 
cravings,  negative  mood,310  sleep  disturbances311 
and  tension.312  One  study  found  that  exercisers 
in  a  smoking  cessation  program  were  twice  as 
likely  as  those  who  did  not  exercise  to 
demonstrate  continual  abstinence  by  the  end  of 
the  three-month  program,  and  three  and  12 
months  following  treatment  completion.  After  a 
year,  exercise  participants  were  36  percent  less 


5  A  neurotransmitter  involved  in  mood,  emotion, 
sleep,  appetite  and  some  aspects  of  addiction. 


-106- 


likely  than  those  who  did  not  exercise  to  have 
relapsed.313 

Chronic  Disease  Management 

Although  the  reasons  are  not  yet  clear,  some 
individuals  may  experience  one  episode  in 
which  their  symptoms  meet  clinical  diagnostic 
criteria  for  addiction  and  be  non-symptomatic 
thereafter.314  In  many  cases,  however,  addiction 
manifests  as  a  chronic  disease-a  persistent  or 
long-lasting  illness— which  requires  ongoing 
professional  treatment  and  management.315  This 
may  be  due  to  a  preexisting  brain  dysfunction  or 
to  changes  that  occur  in  the  brain  in  response  to 
repeated  exposure  to  addictive  substances  which 
increase  the  vulnerability  of  the  individual  to 
relapse,  even  after  cessation  of  substance  use.316 

All  chronic  diseases— regardless  of  whether  they 
are  genetically  based,  driven  by  biological  or 
environmental  influences  or  originate  from  some 
combination  of  these  factors-require  long  term, 
evidence-based  medical  management  of  the 
disease  by  qualified  health  professionals  and 
may  include  pharmaceutical  and/or  psychosocial 
therapies  as  indicated,  to  assure  that  patients 
remain  symptom  free  and  that  co-occurring 
health  conditions  and  the  patient's  nutrition  and 
exercise  requirements  are  addressed.317 

Chronic  disease  management  can  improve 
patient  functioning,  suppress  symptoms,  prevent 
the  development  of  additional  diseases  or  co- 
occurring  conditions  and  reduce  relapse.318 

Relapse  can  result  from  a  wide  range  of  factors 
including  cravings  and  withdrawal  symptoms; 
interpersonal  conflict,  peer  pressure  and  other 
stressors;  and  the  patient's  emotional  state, 
motivation  level,  self-efficacy  and  ability  to 
cope  with  high-risk  situations.319  Recent 
research  also  points  to  individual  differences  in 
brain  structure  as  a  risk  factor  for  relapse: 
patients  in  treatment  for  addiction  involving 
alcohol  who  had  reduced  volumes  of  gray 
matter*  in  the  regions  of  the  brain  associated 


Gray  matter  volumes  were  measured  via  magnetic 
resonance  imaging  (MRI).  Gray  matter  is  considered 
a  reliable  indicator  of  neural  count  and  functionality. 


with  impulse  control  and  cognitive  function 
were  more  likely  to  relapse  after  a  shorter  period 
of  time  than  those  with  higher  volumes  of  gray 
matter  in  these  brain  regions.320  Yet  another 
obvious  but  rarely  considered  factor  that  may 
contribute  to  relapse  risk  is  that  the  treatment  the 
patient  received  simply  was  inadequate,  either  in 
terms  of  the  type  of  intervention  provided  or  the 
length  or  intensity  of  the  treatment.321 

Chronic  disease  management,  as  it  applies  to 
addiction  treatment  and  relapse  prevention, 
seeks  to  address  and  prevent  those  factors  that 
increase  the  likelihood  of  relapse  by  ensuring 
that  treatment  delivery  is  effective  and  that 
personal,  psychological  and  environmental  risk 
factors  for  relapse  are  addressed  and 
mitigated.322  Specifically,  physicians 
supervising  addiction  treatment  should  assess 
the  need  for  chronic  disease  management  and 

323 

ensure  continuing  care. 

Medically  Supervised  Disease  Management 

Health  care  providers  are  optimally  situated  to 
provide  clinical  disease  management.324 
Following  acute  treatment,  the  disease 
management  process  is  critical  to  help  maintain 
health  and  prevent  relapse.325 

Patients  who  have  received  acute  treatment  for 
addiction  may  require  maintenance  medications 
such  as  methadone,  buprenorphine,  naltrexone, 
disulfiram  or  NRT  to  prevent  relapse.326  Since 
many  patients  with  addiction  have  co-occurring 
health  conditions  that  may  complicate  their 
treatment  or  exacerbate  the  risk  of  relapse, 
medical  professionals  should  carefully  supervise 
and  coordinate  treatment  for  all  conditions.327 
Medical  professionals  supervising  patient  care 
also  may  perform  toxicology  screens  to  monitor 
patients'  substance  use  following  acute 
treatment  and  modify  clinical  interventions 
accordingly.328 

Medical  professionals  also  should  supervise  the 
psychosocial  interventions  that  patients  receive 
following  acute  addiction  treatment. 
Psychosocial  therapy  often  is  a  critical 
component  of  relapse  prevention.329 
Collaborating  with  other  health  professionals,  as 


-107- 


needed,  physicians  should  work  to  educate 
patients  about  the  precipitants  of  cravings  and 
relapse  and  help  them  to  cope  adaptively  with 
the  associated  psychological  and  environmental 
risk  factors. 


The  Physician  Health  Program 

An  addiction  treatment  model  that  provides 
effective  long-term  disease  management  is  the 
Physician  Health  Program  (PHP)  established  by 
state  medical  societies  and  licensing  boards  to  treat 
physicians  who  have  addiction.330  Today,  all  50 
states  and  the  District  of  Columbia  have  a  PHP.331 
The  PHP  assists  the  participating  physician  in 
finding  clinical  treatment  services,332  provides  case 
management  of  individuals  undergoing  treatment 
and  maintains  relationships  with  the  authorized 
treatment  facilities  that  evaluate  and  treat  referred 
physicians.333  Contingency  management  in  the 
form  of  negative  consequences  for  violating  its 
terms  (e.g.,  losing  one's  license  to  practice 
medicine,  malpractice  suits,  disciplinary  actions 
from  hospital  boards)  is  a  critical  part  of  the 
program.334  PHPs  must  have  the  oversight  of  a 
medical  director;  some  have  an  MD  on  staff  who 
serves  as  a  medical  consultant.335 

Treatment  managed  by  a  PHP  is  more  intense  and 
lasts  longer  than  that  for  the  general  population, 
with  three  to  six  months  spent  in  structured  therapy 
followed  by  five  years  of  contingency  management, 
and  it  includes  pharmaceutical  therapy, 
psychosocial  interventions  and  nutrition  and 
exercise  counseling.336  PHPs  also  typically  have  a 
mutual  support  program  component.337  Long-term 
monitoring  is  employed  to  reduce  relapse:  when 
relapse  or  signs  of  possible  relapse  occur,  the 
reaction  is  therapeutic,  not  punitive.338  Physicians 
who  relapse  tend  to  improve  again  after  a  treatment 
adjustment.339 

More  than  80  percent  of  physicians  who  participate 
in  PHPs  return  to  work  and  remain  substance  free 
for  a  minimum  of  five  years  after  receiving 
treatment.340  Seventy-one  percent  of  participating 
physicians  retain  their  medical  license  and  are 
employed  after  five  years.341 

Key  elements  of  the  PHP  program  that  appear  to 
contribute  to  its  success  and  that  are  replicable  in 
the  general  population  include  high  intensity  care 
for  an  extended  duration  and  the  inclusion  of  long- 
term  monitoring  and  disease  management.342 


Case  Management 

Many  of  the  activities  involved  in  chronic 
disease  management  and  oversight  can  be 
performed  by  professionally-trained  case 
managers  working  in  a  variety  of  settings  such 
as  physicians'  offices,  hospital  or  out-patient 
addiction  treatment  programs,  justice  facilities 
or  social  service  agencies.  They  should, 
however,  work  under  the  supervision  of  a 
trained  physician  and  other  medical 
professionals.343 


A  Case  Management  Approach: 
Recovery  Management  Checkups 

Recovery  Management  Checkups  (RMC)— in 
which  patients  are  contacted,  evaluated  and 
linked  to  additional  support  services  including 
those  that  address  co-occurring  conditions-have 
been  shown  to  be  an  effective  approach  to 
chronic  disease  management  by  helping  patients 

i  •  "S44 

engage  in  and  stay  in  treatment. 

Research  finds  that  adolescents  and  adults  in 
addiction  treatment  who  receive  RMCs-based 
on  a  method  that  involves  locating  individuals 
for  checkup,  assessing  eligibility  for 
intervention,  linking  individuals  to  treatment 
services,  engaging  participants  in  treatment  and 
retaining  participation  for  at  least  14  days  in 
residential  treatment  or  seven  days  in  intensive 
or  regular  outpatient  treatment— demonstrate 
higher  levels  of  treatment  participation  and 
abstinence  rates  and  reduced  time  to 
readmission  for  treatment  following  relapse.345 
Patients  receiving  such  checkups  were 
significantly  likelier  than  patients  receiving 
usual  care  to  return  to  treatment  (55  percent  vs. 
37  percent),  do  so  sooner  (384  days  earlier)  and 
to  be  abstinent  (480  days  vs.  430  days)  over  a 
two-year  follow-up.346 


Professional  case  managers  can  help  to  navigate 
and  coordinate  resources  within  the  fragmented 
health  care  system  and  ensure  that  patients 
receive  the  services  they  need  to  keep  addiction 
symptoms  in  check.347  The  role  of  the  case 
manager  is  to  link  patients  to  the  health  and 
social  services  appropriate  to  their  specific 
needs,  ensure  that  patients  follow  through  with 
referrals,  help  patients  identify  and  access  a 


-108- 


variety  of  additional  support  programs  including 
family  and  peer  support  and  auxiliary  services, 
provide  educational  materials  on  relapse 
prevention  and  promptly  intervene  in  the  case  of 
relapse.348  Monitoring  the  course  of  a  patient's 
treatment  and  connecting  patients  with  services 
when  they  are  needed  are  common  public  health 
approaches  to  addressing  chronic  illnesses.349 


Case  management  is  associated  with  an 
increased  chance  that  people  with  addiction  will 
access  treatment  for  relapse,  remain  in  treatment 
for  a  longer  period  of  time350  (which  is 
associated  with  better  treatment  outcomes), 
utilize  support  services351  and  demonstrate 


improved  social  outcomes.*  352  A  meta-analysis 
of  case  management  for  patients  in  treatment  for 
addiction  involving  alcohol  or  drugs  other  than 
nicotine  found  that  case  management  can 
improve  patients'  family  and  social 
relationships,  living  situations  and  health.353 

Support  Services 

Comprehensive  care  for  patients  with  addiction 
requires  not  only  proper  assessment, 
stabilization,  acute  care  and  chronic  disease 
management,  but  support  services  as  well. 
These  may  include: 

•  Mutual  support  programs  to  bolster  disease 
management  efforts  and  avoid  the 
recurrence  of  disease  symptoms;  and 

•  Auxiliary  support  services  to  address  legal, 
educational,  employment,  housing, 
parenting  and  child-care  issues  that  may 
impede  disease  management.356 

Health  care  providers  are  optimally  situated  to 
facilitate  links  to  these  support  and  auxiliary 

357 

services. 

Mutual  Support  Services 

Mutual  support  programs,  sometimes  referred  to 
as  self-help  groups,  can  be  a  significant  part  of  a 
comprehensive  approach  to  caring  for  a  patient 
with  addiction.  In  fact,  for  many  people  with 
addiction,  these  programs  have  been  the  main 
help  available  to  them  and  have  been  both 
lifesaving  and  critical  to  helping  them  manage 
their  disease.358  These  programs  allow 
individuals  with  addiction  to  seek  and  provide 
social,  emotional  and  informational  support 
within  a  group  of  their  peers.  Participation  in 
these  programs  can  increase  the  chances  of 
achieving  and  maintaining  abstinence  as  well  as 


In  one  study,  veterans  with  addiction  involving 
illicit  drugs  who  were  assisted  by  case  managers 
experienced  a  larger  increase  in  the  number  of  days 
they  spent  gainfully  employed  than  their  peers  who 
went  unassisted  which,  in  turn,  was  associated  with 
lower  rates  of  substance  use,  incarceration  and  arrests 
resulting  in  convictions. 


An  Example  of  an  Effective  Case 
Management  Program  for  Women 

CASASARDSM  is  a  welfare  demonstration 
program  for  mothers  in  Essex  and  Atlantic 
counties  in  New  Jersey  who  have  addiction.  The 
program  is  designed  to  get  women  engaged  in 
treatment  and  employment  services,  help  them 
become  sober  and  move  successfully  to  stable 
employment.  CASASARDSM  uses  an  intensive 
case  management  approach  to  provide  services 
for  these  women. 

CASA  Columbia's  research  has  found  that 
women  with  addiction  involving  alcohol  or  other 
drugs  (excluding  nicotine)  who  receive  income 
assistance  through  CASASARDSM  were  more 
likely  to  initiate  treatment  (66.5  percent  vs.  50.3 
percent)  and  complete  their  programs  (43.5 
percent  vs.  22.7  percent)  if  they  were  provided 
with  case  management  services  rather  than 
standard  care.  Looking  at  abstinence  as  one 
outcome  measure,  over  a  12-month  post-referral 
period,  women  participating  in  the 
CAS ASARDSM  program  had  a  64  percent  higher 
monthly  abstinence  rate  than  their  peers  in  the 
standard  care  program,  and  were  likelier  to  have 
remained  completely  abstinent  by  the  end  of  the 
12-month  period  (41  percent  vs.  25  percent).354 
After  another  12  months,  the  abstinence  rate 
among  CASASARDSM  participants  had 
increased  to  47  percent  while  the  abstinence  rate 
among  non-participants  remained  relatively 
unchanged  (24  percent).355 


-109- 


help  patients  reduce  their  substance-related 
problems.359  They  are  incorporated  into  many 
formal  treatment  programs,  can  be  an  important 
part  of  chronic  disease  management  and 
constitute  the  most  frequently-accessed  resource 
among  people  with  addiction  involving  alcohol 
and  other  drugs  and  related  problems.360 
National  data  indicate  that  an  average  of  five 
million  people  ages  12  and  older  attend  an 
alcohol  or  other  drug  use  mutual  support  group 
each  year.  Slightly  less  than  half  (45.3  percent) 
of  the  attendees  participated  in  support  groups 
for  addiction  involving  alcohol;  21.8  percent 
participated  in  support  groups  for  addiction 
involving  other  drugs  and  33.0  percent 
participated  in  support  groups  for  co-occurring 
addiction  involving  alcohol  and  other  drugs.* 361 

Although  there  are  many  types  of  mutual 
support  programs,  most  have  many 
characteristics  in  common:362 

•  Group  members  share  the  same  problem  or 
status; 

•  Groups  are  run  using  self-directed 
leadership;  that  is,  members,  rather  than  an 
outside  governing  figure,  are  in  charge  of 
the  program; 

•  Group  members  share  their  experiences  and 
lessons  learned; 

•  Members  share  the  goal  of  changing  some 
aspect  of  their  personal  behavior; 

•  Reciprocal  helping  is  the  norm; 

•  Members  participate  on  a  voluntary  basis; 
and 

•  Programs  may  accept  donations  but  do  not 
charge  for  membership.363 

Some  organizations  focus  more  on  providing 
fellowship,  information  or  self-acceptance  while 
others  attempt  to  address  the  origin  of 


Comparable  data  on  rates  of  participation  in 
Nicotine  Anonymous  are  not  available. 


participants'  addiction  problems.  Programs 
also  vary  in  terms  of  the  methods  used  to 
address  addiction,  the  extent  to  which  there  is  an 
emphasis  on  spirituality  or  religion,  whether 
members  are  encouraged  to  participate  in 
political  advocacy, '  whether  friends  and  family 
members  are  included  in  group  meetings,  the 
extent  to  which  the  group  facilitates  connection 
with  treatment  professionals  working  in  an 
advisory  role*  and  whether  the  program  accepts 
external  funds.365 

The  12-step  groups,  such  as  Alcoholics 
Anonymous  (AA)  and  Narcotics  Anonymous 
(NA)  are  some  of  the  best  known  and  most 
widely  available  mutual  support  programs.5  366 
They  provide  participants  with  12  steps  to 
follow  during  the  process  of  recovery.367  These 
programs  generally  begin  with  the  acceptance  of 
one's  addiction  and- thro  ugh  a  process  of  self- 
exploration— participants  take  action  to  make 
changes  toward  recovery.368 

Other  core  components  of  these  programs  are 
taking  responsibility  for  the  recovery  process, 
sharing  personal  experiences,  recognizing  the 
existence  of  a  higher  power,  helping  others  and 
lifetime  commitment  to  the  program.369  Outside 
of  the  group  meetings,  sponsorship"  plays  an 
important  role  in  most  12-step  programs.  Each 
new  group  member  finds  a  sponsor  to  serve  as  a 
role  model,  program  guide  and  first  line  of 
support  in  the  case  of  a  potential  or  actual 
relapse.370  It  is  estimated  that  AA,  the  oldest 


'  e.g.,  unlike  organizations  such  as  Alcoholics 
Anonymous  (AA)  and  Narcotics  Anonymous  (NA) 
which  require  anonymity,  the  Faces  and  Voices  of 
Recovery  organization  seeks  to  organize  and 
mobilize  individuals  with  histories  of  addiction,  their 
families  and  friends  in  public  policy  advocacy 
efforts. 

*  Professionals  may  work  in  an  advisory  role  or  they 
may  serve  as  guest  lecturers. 
§  There  also  are  12-step  programs  for  individuals 
dealing  with  gambling  and  other  types  of  addiction, 
and  with  a  family  member's  or  friend's  addiction, 
such  as  Al-Anon  and  Alateen. 

**  Sponsors  typically  have  completed  at  least  one  year 
of  abstinence  with  the  program  and  are  of  the  same 
sex  as  the  new  member  (or  a  different  sex  for  gay 
members). 


-110- 


and  best  known  of  the  12-step  programs,  has 
more  than  2,000,000  members  in  more  than 
1 14,000  groups  in  more  than  180  different 

371 

countries. 

Other  examples  of  mutual  support  programs  that 
do  not  follow  the  traditional  12-steps  approach 
and  that  are  secular  in  nature  include  SMART 
Recovery  (Self-Management  and  Recovery 
Training),372  Secular  Organizations  for  Sobriety 
(SOS),  Women  for  Sobriety  and  LifeRing 
Secular  Recovery.373  Groups  vary  based  on  the 
population  they  serve.374 

Participation  in  mutual  support  programs- 
including  12-step  and  secular-based  programs- 
has  been  associated  with  improved 
psychological  functioning,  reduced  substance 
use  and  reduced  health-care  costs  and 
utilization.375  However,  there  are 
methodological  limitations  to  the  effectiveness 
studies  that  examine  mutual  support  programs, 
restricting  the  extent  to  which  their  ability  to 
curb  substance  use  and  help  manage  addiction 
can  be  determined.376  Most  are  not  randomized 
controlled  studies,  research  on  the  programs  is 
difficult  to  conduct  due  to  the  anonymous  nature 
of  group  membership377  and  there  may  be  an 
inherent  bias  in  the  research  in  that  AA  and 
other  12-step  groups  may  attract  patients  who 
are  more  motivated  to  change.378  Despite  the 
limited  empirical  evidence  demonstrating  the 
effectiveness  of  mutual  support  programs  like 
AA,  anecdotal  evidence  of  their  effectiveness 
abounds.379 

One  finding  that  emerges  consistently  from  the 
available  research  is  that  patients  who  had  been 
in  addiction  treatment  and  then  followed  up  with 
involvement  in  mutual  support  programs  fare 
better  than  those  who  do  not.380  A  study  that 
followed  treatment  patients  with  addiction 
involving  alcohol  for  three  years  found  that 
those  who  were  more  involved  with  mutual 
support  programs  were  likelier  than  other 
patients  to  be  abstinent  the  next  year.  Mutual 
support  program  members  who  were  not 
abstinent  the  year  following  group  participation 


Including,  but  not  limited  to,  AA,  SMART 
Recovery  and  Women  for  Sobriety. 


still  drank  less  on  the  days  that  they  did  consume 
alcohol.381  Other  research  finds  that  those  who 
attend  AA  or  another  12-step  group  following 
treatment  have  about  twice  the  rate  of  abstinence 
as  those  who  do  not  participate  in  these  mutual 
support  programs. 

Reviews  of  the  research  on  the  effectiveness  of 
mutual  support  programs  suggest  that  it  may  not 
be  the  specific  content  of  the  programs  or  their 
processes  that  are  associated  with  positive 
outcomes,  but  rather  the  fact  that  they  provide 
free,  long-term  and  easily-accessible  exposure  to 
people  and  messages  that  support  recovery,383 
which  is  a  key  element  of  chronic  disease 
management.384 

Twelve  Step  Facilitation.  Twelve  Step 
Facilitation  (TSF)  is  a  formalization  and 
professionalization  of  the  12-step  mutual  support 
model  which  involves  a  brief,  structured  and 
manual-driven  approach  implemented  over  the 
course  of  12  to  15  sessions  by  a  trained 
counselor  or  treatment  provider.385  During  these 
sessions,  providers  will  advocate  abstinence, 
explain  the  basic  concepts  of  the  12-steps  and 
actively  support  and  facilitate  the  patient's 
involvement  in  12-step  programs.  TSF  can  be 
implemented  in  an  individual  or  group  format  or 
including  the  patient's  significant  other.  It  has 
been  used  in  acute  treatment  and  as  a  method  of 
providing  support  services  for  chronic  disease 
management.386 

TSF  has  been  used  to  address  addiction 
involving  alcohol,387  marijuana  and 
stimulants.388  Evaluations  of  TSF  are  limited; 
however,  several  studies  have  found  it  to  be 
comparable  in  effectiveness  to  psychosocial 
treatments  such  as  CBT  and  MET.389  It  is  listed 
in  SAMHSA's  National  Registry  of  Evidence- 
based  Programs  and  Practices390  and  as  an 
evidence-based  approach  by  the  National 
Institute  on  Drug  Abuse  (NIDA).391 

Residential  Programs.  Some  mutual  support 
approaches,  such  as  the  Therapeutic  Community 
(TC)  model,  are  residential  and  incorporate 
elements  of  treatment.  Other  residential 
programs  such  as  recovery  homes  or  sober  living 
houses  provide  mutual  support  only.  These 


-111- 


programs  are  non-professional,  generally  low- 
cost  communal  homes  that  provide  supportive, 
substance-free  living  environments  to 
individuals  attempting  to  establish  or  maintain 
sobriety.392  Homes  may  be  democratically  run 
or  hierarchically  structured  with  house  managers 
in  charge  of  other  residents.  Typically, 
participation  in  additional  aftercare  services  is 
encouraged  or  required.393 

Therapeutic  Communities.  The  TC  model,  used 
primarily  but  not  exclusively  with  the  justice 
population,  is  a  highly  structured  residential 
program  that  requires  a  long-term  commitment 
(six  to  24  months).394  It  is  based  on  mutual 
support  principles  and  incorporates  behavior 
modification  techniques,  education  classes  and 
residential  job  duties.395  This  approach  aims  to 
re-socialize  the  patient  to  a  substance-free, 
crime-free  lifestyle  through  peer  influence, 
personal  responsibility  and  skill  training.396  TC 
participants  commonly  include  individuals  with 
relatively  long  histories  of  addiction, 
involvement  in  serious  criminal  activities  and 
significantly  impaired  social  functioning.397  The 
mutual  support  aspect  of  TCs  operates  on  a 
hierarchical  basis;  patients  who  have  been 
involved  in  the  program  longer  provide  support 
and  serve  as  role  models  for  newer  patients.398 

A  large,  national  study  found  that  patients 
enrolled  for  at  least  90  days  in  a  TC1  were 
significantly  less  likely  to  have  used  cocaine  (28 
percent  vs.  55  percent),  tested  positive  for  drug 
use  (19  percent  vs.  53  percent),  reported  daily 
alcohol  use  (9  percent  vs.  15  percent)  or  have 
spent  time  in  jail  (24  percent  vs.  54  percent)  a 
year  after  program  participation  than  those  who 
spent  fewer  than  90  days  in  the  program.399  The 
year  following  successful  TC  completion 
showed  lasting  effects  along  several  indicators 
compared  to  the  year  prior  to  TC  entry:  the  rate 
of  weekly  cocaine  use  fell  from  66.4  percent  to 

22.1  percent;  weekly  heroin  use,  from  17.2 
percent  to  5.8  percent;  heavy  alcohol  use,  from 

40.2  percent  to  18.8  percent;  illegal  activity, 
from  40.5  percent  to  15.9  percent;  less  than  full- 


Not  defined. 
*  Long-term  residential  programs,  most  of  which 
were  TCs. 


time  employment,  from  87.6  percent  to  77.0 
percent;  and  reported  suicidal  thoughts,  from 
23.6  percent  to  13.2  percent.400 

For  patients  with  co-occurring  mental  health 
disorders,  a  Modified  Therapeutic  Communities 
(MTC)  model  takes  into  account  patients' 
psychiatric  symptoms,1  potential  cognitive 
impairments  and  reduced  levels  of  functioning 
due  to  substance  use,  including  poor  control 
over  urges  and  short  attention  spans.  MTCs  are 
more  flexible,  less  intense  and  more 
individualized  than  standard  TCs.401 

Sober  Living  Houses.  Sober  Living  Houses 
provide  a  substance-free  living  environment  for 
individuals  with  addiction  involving  alcohol, 
illicit  drugs  and  controlled  prescription  drugs. 
No  formal  treatment  services  are  provided  but 
residents  are  mandated  or  strongly  encouraged 
to  participate  in  mutual  support  programs  and 
must  comply  with  house  rules  which  include 
maintaining  abstinence,  paying  rent, 
participating  in  house  chores  and  attending 
house  meetings.402  Failure  to  comply  with  these 
rules  results  in  dismissal  from  the  home.403 

One  study  of  the  combination  of  participating  in 
a  sober  living  house  and  receiving  outpatient 
treatment  interviewed  participants  within  their 
first  week  of  entering  the  houses  and  again  at 
six-,  12-,  and  18-month  follow-ups. §  The  study 
found  significant  improvements  over  time  on 
measures  of  alcohol  and  other  drug  use,  arrests 
and  employment.404 

The  Oxford  House  Model.  Oxford  House, 
founded  in  1975,  is  one  of  the  most  prevalent 
and  well-studied  examples  of  communal-living 
environments  of  this  nature.405  Unlike  sober 
living  houses,  they  encourage  but  never  mandate 
participation  in  mutual  support  programs.406 
Typically,  eight  to  1 5  residents  of  the  same  sex 
live  in  each  home.  Most  recently  have  received 
detoxification  or  some  form  of  treatment  and 
many  have  been  homeless  or  spent  time  in  jail  at 


1  Although  care  is  not  medically-supervised. 
§  The  average  length  of  stay  in  the  sober  living 
houses  was  over  five  months  but  there  was 
considerable  variation. 


-112- 


some  point  in  their  lives.     Homes  are  run 
independently  by  the  residents;  there  are  no  on- 
site  professional  treatment  providers.  The 
homes  are  supported  financially  by  residents 
who  are  required  to  pay  the  rent  on  time  and 
maintain  their  sobriety.   Contrary  to  a  chronic 
disease  management  approach,  members  who 
relapse  are  expelled  immediately  from  the  house 
and  must  demonstrate  30  days  of  sobriety  before 
reapplying  for  residence.408  Residents  are 
expected  to  attend  weekly  meetings  where  house 
issues  are  discussed  and  where  they  are 
encouraged  to  attend  mutual  support 

409 

programs. 

One  study  found  that  two  years  after  completing 
treatment  and  entering  an  Oxford  House,  current 
and  former  residents  were  more  successful  at 
decreasing  their  use  of  alcohol  and  other  drugs 
than  those  who  completed  treatment  but  simply 
received  standard  aftercare  referrals  to  outpatient 
programs  or  self-help  groups.410  Over  that 
period,  those  who  lived  in  an  Oxford  house  were 
less  than  half  as  likely  as  those  who  received 
usual  care  to  use  any  substance  (31.3  percent  vs. 
64.8  percent),  less  likely  to  be  currently  facing 
criminal  charges  (0.0  percent  vs.  5.6  percent) 
and  more  likely  to  be  employed  (76.1  percent  vs. 
48.6  percent)  two  years  later.  Only  15.6  percent 
of  participants  who  had  lived  in  an  Oxford 
House  for  at  least  six  months  relapsed  after  two 
years  and  residents  ages  36  and  younger 
demonstrated  a  two-year  relapse  rate  of  only  6.7 

411  ~  ' 

percent. 

Auxiliary  Support  Services 

Patients  who  complete  treatment  successfully 
may  find  themselves  facing  relapse  due  to  the 
anxiety  of  coping  with  other  health  problems, 
unemployment,  child  care,  homelessness, 
criminal  justice  and  other  social  problems.412 
Matching  patients  with  the  services  necessary  to 
address  these  problems  decreases  the  risk  of 
relapse.413 


New  houses  often  are  started  with  federal  or  state 
loans  stemming  from  the  1988  Anti-Drug  Abuse  Act; 
the  loans  are  paid  back  by  the  residents. 


According  to  data  from  a  national  multi-site 
study  of  a  variety  of  treatment  modalities,  the 
majority  of  treatment  patients'  perceived  a  need 
for  auxiliary  support  services  including  family 
counseling  services  (70.9  percent), 
supplementary  medical  care  (63.5  percent), 
mental  health  care  (63.4  percent),  housing  (63.0 
percent)  and  vocational  services  (61.4 
percent).414  (Figure  5.A) 


Figure  5.A 

Addiction  Treatment  Patients'  Perceived 
Needs  for  Auxiliary  Services 


70.9 

63.5 

63.4 

63.0 

61.4 

Family  Supplementary  Mental  Health  Housing  Vocational 
Counseling    Medical  Care       Care  Services 


Source:  CASA  Columbia  analysis  of  Friedmann  et  al  (2004). 


The  perceived  needs  for  supplementary  medical, 
including  mental  health,  care  underscore  the 
historic  disconnect  of  addiction  treatment  from 
medical  care.  Individuals  who  had  their 
perceived  needs  for  vocational  and  housing 
services  met  showed  significant  reductions  in 
illicit  drug  use.'  415 

Evidence  from  a  smaller  study  also 
demonstrated  that  matching  treatment  patients 
with  services  they  need  can  decrease  the  severity 
of  their  substance  use.*  Six-months  after 
enrolling  in  the  study,  patients  who  reported  a 
need  for  housing  services  and  had  their  needs 
matched  experienced  a  greater  reduction  in  their 
substance  use  severity  score  compared  to 
patients  with  housing  needs  who  were  not 
matched  to  services  (50  percent  vs.  23  percent 


'  Patients'  needs  were  determined  by  their  rating  of  a 
service  as  "somewhat  or  very  important."  Because 
patients  were  not  randomly  assigned  to  receive 
services,  the  reductions  in  illicit  drug  use  cannot  be 
linked  directly  to  having  their  perceived  service 
needs  met. 

*  As  measured  by  the  Addiction  Severity  Index. 

-113- 


reduction).   Similarly,  patients  who  reported  a 
need  for  child  care  services  and  had  their  needs 
addressed  experienced  a  greater  reduction  in 
their  substance  use  severity  score  compared  to 
patients  with  child  care  needs  who  were  not 
matched  to  needed  services  (45  percent  vs.  20 
percent).'  416 

The  Use  of  Technology  in  Addiction 
Treatment  and  Disease 
Management 

An  emerging  approach  to  identifying,  treating 
and  managing  addiction-the  utilization  of  online 
computer  tools  and  other  technology-based 
interventions  to  enhance  access  and  delivery— is 
showing  some  promising  results.417  These 
include  telephone  contact  with  treatment 
providers  and  e-mail,  text  messaging, 
smartphone  apps  and  online  support  groups.418 

Online  approaches  that  employ  evidence-based 
practices  via  Web  sites  or  tele-  or  video- 
conferencing offer  key  advantages.  They  can 
provide  psychosocial  therapies  to  patients  at 
lower  cost  than  traditional  face-to-face 
approaches.419  They  allow  patients  who  live  far 
from  specialty  treatment  providers  or  who  lack 
resources  to  access  psychosocial  therapies  or 
supplemental  services  in  a  convenient  manner.420 

Researchers  are  just  beginning  to  investigate  the 
utility  of  technology-based  services  for  patients 
with  addiction.  While  most  existing  studies  are 
methodologically  weak  or  flawed,421  a 
randomized  controlled  trial  of  a  digitally- 
delivered  smoking  cessation  intervention  found 
significantly  higher  long-term  abstinence  rates 
compared  to  a  control  group  receiving  only  a 
self-help  booklet  (22.3  percent  vs.  13.1 
percent).422  Another  randomized  control  study 
found  that  patients  enrolled  in  a  methadone 
maintenance  program  who  participated  in 
Internet-based  group  therapy  sessions  reported 


There  was  a  41  percent  reduction  among  patients 
who  never  reported  needing  the  services.  Patients 
were  not  randomly  assigned  to  receive  services. 
'  There  was  a  3 1  percent  reduction  among  those  who 
never  reported  needing  the  service. 


greater  satisfaction  with  the  program  than 
patients  who  participated  in  traditional,  face-to- 
face  group  therapy  sessions;  reductions  in 
positive  drug  urine  tests  during  the  six-week 
study  were  comparable  between  the  two  groups, 
suggesting  that  Internet-based  therapy  may  be  an 
effective  treatment  tool.423  A  recent  study  found 
that  a  smartphone-based  support  system  shows 
potential  for  preventing  relapse  in  addiction 
involving  alcohol;424  however,  further  research 
is  needed  on  this  particular  program  and,  more 
generally,  on  the  outcomes  of  technology-based 
services  and  how  they  compare  to  traditional 
service  delivery  methods.425 

Concerns  about  technology-based  services 
include  the  risks  to  privacy  and  confidentiality 
of  information  transmitted  over  the  Internet, 
safety  and  efficacy,  and  issues  of  licensing 
posed  by  treatment  delivered  across  state 
lines.426 

Public  Attitudes  about  Addictive 
Substances  and  the  Need  for 
Addiction  Treatment 

Although  the  American  public  appears  to  be 
supportive  of  assuring  that  individuals  with 
addiction  receive  effective  addiction  treatment, 
the  view  of  most  individuals  about  the  relative 
need  for  treatment  for  individuals  who  use 
addictive  substances  and  what  constitutes 
effective  treatment  does  not  match  the  science  of 
best  practices. 

Perceptions  of  the  Relative  Need  for 
Treatment  Based  on  Substance  of 
Addiction 

CAS  A  Columbia's  NAB  AS  found  significant 
differences  in  respondents'  views  of  the  type  and 
extent  of  substance  use  that  indicates  a  substance 
use  problem  and  the  need  to  seek  treatment. 
Public  perceptions  do  not  reflect  the  continuum 
of  substance  use  or  distinguish  between  risky 
use  and  the  need  for  intervention  versus 
addiction  and  the  need  for  treatment: 

•    The  majority  of  respondents  reported  that 
any  use  of  the  illegal  drugs  heroin  (84.0 


-114- 


percent),  cocaine  (76.0  percent)  or 
methamphetamine  (73.9  percent)  indicates 
that  the  user  has  a  serious  problem  and 
should  seek  treatment. 

42.5  percent  thought  that  any  misuse  of  a 
controlled  prescription  drug  is  a  serious 
problem  requiring  treatment;  29.6  percent 
thought  that  daily  or  more  than  daily  misuse 
of  these  drugs  is  serious  enough  to  require 
treatment. 

35.8  percent  felt  that  any  use  of  marijuana 
indicates  that  the  user  has  a  serious  problem 
and  should  seek  treatment;  the  same  amount 
(35.9  percent)  thought  that  daily  or  more 
than  daily  use  of  marijuana  is  a  serious 
problem  that  requires  treatment. 


complete  abstinence  should  be  the  main  goal  of 
treatment  for  individuals  with  addiction 
involving  illicit  drugs  (65.7  percent),  alcohol 
(60.0  percent),  tobacco  (50.1  percent)  or 
controlled  prescription  drugs  (47.1  percent). 
Whereas  the  next  most  common  response  for  the 
goal  of  addiction  treatment  was  that  the  goal 
should  be  set  by  the  patient,  a  small  but 
significant  proportion  indicated  that  reduced  use 
should  be  the  primary  goal;  this  was  particularly 
true  for  addiction  involving  prescription  drugs,' 
tobacco  and  alcohol,  but  less  so  for  addiction 
involving  illicit  drugs.  A  focus  solely  on 
reducing  the  negative  consequences  of  substance 
use  (the  "harm  reduction"  approach)  rather  than 
reducing  or  eliminating  use  was  endorsed  by 
fewer  than  five  percent  of  the  respondents  as  a 
main  goal  of  treatment.428  (Figure  5.B) 


78.0  percent  reported 
that  alcohol  use  is  a 
serious  problem 
requiring  treatment  if 
it  occurs  daily  or 
more  than  daily;  6.8 
percent  reported  that 
any  drinking  is  a 
serious  problem 
requiring 


treatment. 


427 


49.5  percent  felt  that 
smoking  was  a 
serious  problem 
requiring  treatment  if 
it  occurred  on  a  daily  or  more  than  daily 
basis;  24.3  percent  reported  that  any 
smoking  is  a  serious  problem  requiring 
treatment. 


Figure  5.B 

Public  Perceptions  of  the  Goals  of  Treatment 


60.0 


50.1 


n 


47.1 


29.7 


21.1 


"114.6 


7.6 


22.7 


20.! 


3.5 


Illicit  Drugs 


Alcohol 


Tobacco 


Prescription  Drugs 


i  Complete 
Abstinence 


i  Goal  Set  by 
Patient 


i Reduced  Use 


1  Fewer  Negative 
Consequences 


Source:  CASA  Columbia  National  Addiction  Belief  and  Attitude  Survey  (NABAS),  2008. 


Perceptions  of  the  Goals  of  Treatment 

From  a  medical  perspective,  the  goal  of 
addiction  treatment  would  be  to  restore  and 
maintain  health  and  eliminate  or  reduce  risky 
behavior  that  threatens  health  and  safety.  Most 
respondents  to  the  NABAS  indicated  that 


In  the  NABAS  survey,  respondents  were  asked 
which  of  the  following  they  thought  should  be  the 
main  treatment  goal  for  someone  with  addiction 


involving  tobacco,  alcohol,  illicit  drugs  and 
prescription  drugs:  complete  abstinence,  reduced 
use,  fewer  negative  consequences  from  use,  or  that 
the  goal  should  be  set  by  the  patient. 
'  For  prescription  drugs,  reduced  use  was  a  more 
common  response  (22.7  percent)  than  that  the  goal 
should  be  set  by  the  patient  (20.8  percent). 


-115- 


Perceptions  of  the  Types  of 
Interventions  that  Constitute  Treatment 

Although  a  wide  range  of  psychosocial  and 
pharmaceutical  therapies  are  available  to 
treat  addiction,  60.1  percent  of  respondents  to 
the  NABAS  spontaneously  offered  mutual 
support  programs  such  as  AA  or  NA  as  a 
"treatment"  intervention  when  asked  what 
kinds  of  treatment  come  to  mind  when  they 
think  about  treatment  for  addiction.  This  is 
despite  the  fact  that  a  mutual  support 
program,  while  a  very  helpful  resource  to 
many  individuals  with  addiction,  is  not  an 
evidence-based  treatment  for  the  disease. 
Forty  percent  (39.9  percent)  mentioned  a 
hospital  visit,  1 1.7  percent  mentioned  residential 
rehabilitation  clinics  and  10.4  percent  mentioned 
outpatient  treatment  as  what  comes  to  mind 
when  they  think  of  addiction  treatment  (although 
these  are  treatment  venues,  not  treatments 
approaches).  Although  only  1 1.6  percent 
mentioned  the  utilization  of  prescription 
medications  for  treating  addiction  (Figure  5.C), 
a  separate  question  found  that  54.7  percent  of 
respondents  (46.8  percent  of  those  with  a  history 
of  addiction)  stated  that  it  is  good  that  there  are 
medicines  to  treat  addiction  because  addiction  is 
a  medical  condition  that  medicine  can  help. 
Perhaps  reflective  of  a  lack  of  knowledge  about 
effective  treatment  for  addiction,  38.3  percent  of 
respondents  (48.6  percent  of  those  with  a 
history  of  addiction)  indicated  it  is  not  good 
news  that  there  are  medicines  to  treat 
addiction  because  treating  addiction  with 
medication  only  serves  to  replace  one 
addiction  with  another 


429 


Some  individuals  with  addiction  may  not 
access  appropriate  treatment  because  of  the 
belief  that  the  use  of  pharmaceutical 
treatments,  such  as  methadone,  to  treat 
addiction  is  contrary  to  the  abstinence-based 
perspectives  of  addiction  treatment  espoused 
by  many  mutual  support/ 12-step  programs.  A 
recent  study  found  that  adherence  to  such 
beliefs  leads  many  heroin  users  to  underutilize 
methadone  maintenance  therapy  despite  their 
knowledge  of  its  effectiveness.430 


Figure  5.C 

Public  Perceptions  of  the  Types  of  Interventions 
that  Constitute  Treatment 


60.1 


39.9 


11.7 


11.6 


10.4 


Mutual  Support  Hospital  Visit     Residential      Prescription  Outpatient 
Program  Rehab  Clinic     Medication  Treatment 

Source:  CASA  Columbia  National  Addiction  Belief  and  Attitude 
Survey  (NABAS),  2008. 


Perceptions  of  the  Effectiveness  of 
Treatment 

Despite  respondents'  limited  awareness  of 
effective  science-based  treatments  for  addiction, 
the  majority  of  respondents  to  the  NABAS 
reported  believing  that  if  a  person  admits  to 
having  a  problem  and  wants  to  get  better, 
addiction  treatment  is  somewhat  or  very 
effective:   approximately  eight  in  10  indicated 
that  treatment  for  addiction  involving  alcohol 
(82.5  percent)  or  prescription  drugs  (79.9 
percent)  is  effective,  and  about  three  quarters 
indicated  that  treatment  for  addiction  involving 
illicit  drugs  (73.6  percent)  and  tobacco  (73.1 
percent)  is  effective.431  (Figure  5.D) 


Figure  5.D 

Percent  of  Public  Agreeing  that 
Addiction  Treatment  Is  Somewhat/Very  Effective, 
by  Substance  Involved 


82.5 

79.9 

73.6 

73.1 

Alcohol 


Prescription  Drugs      Illicit  Drugs 


Tobacco 


Source:  CASA  Columbia  National  Addiction  Belief  and  Attitude 
Survey  (NABAS),  2008. 


It  is  important  to  note,  however,  that  a  significant 
proportion  of  the  public  defines  treatment  in  a  way 
that  is  not  consistent  with  the  science  of  best 
practices  in  treatment. 


-116- 


These  data  are  consistent  with  those  of  other 
recent  surveys.  One  found  that  the  majority  of 
Americans  believe  that  treatment  programs  can 
help  people  with  addiction  involving  alcohol  (8 1 
percent),  prescription  drugs  (79  percent), 
marijuana  (78  percent)  or  other  illicit  drugs  (69 
percent).432  Another  found  that  88  percent  of 
Americans  believe  that  addiction  treatment  is 
extremely  or  very  important  in  helping  people 
get  better  and  77  percent  believe  that  long-term 
recovery  is  unlikely  to  be  successful  without 
treatment  and  continued  support.433 


-118- 


Chapter  VI 

Tailored  Treatment  for  Special  Populations 


Diseases  manifest  differently  in  different 
individuals  and,  as  with  other  health  conditions, 
a  one-size-fits-all  approach  to  addiction 
treatment  typically  is  a  recipe  for  failure.1  For 
addiction  treatment  to  be  effective,  it  must  be 
tailored  to  the  individual  patient,  including  the 
particular  stage  and  severity  of  the  disease, 
overall  health  status  including  any  co-occurring 
conditions,  past  treatments  and  any  other  life 
circumstances  that  might  affect  patient 
outcomes.2  Treatment  approaches  also  must  be 
appropriate  to  the  patient's  age,  gender, 
race/ethnicity  and  cultural  background.3 

Although  research  on  the  effectiveness  of 
various  treatment  approaches  for  special 
populations  is  very  limited,  particular  subgroups 
for  whom  there  is  some  documented  evidence  of 
the  benefits  of  specialized  treatment  include: 
those  with  co-occurring  health  conditions, 
adolescents,  women,  older  adults,  racial  and 
ethnic  minorities,  individuals  of  minority  sexual 
orientation,  veterans  and  those  in  active  duty 
military,  and  individuals  involved  in  the  justice 
system. 

Co-occurring  Medical  Disorders 

Because  addiction  causes,  contributes  to  and  co- 
occurs  with  multiple  other  diseases,  including  70 
other  conditions  requiring  medical  care  such  as 
heart  disease  and  cancer, '  4  physicians  and  other 
medical  professionals  must  address  these  co- 
occurring  health  conditions  in  the  course  of 
caring  for  their  patients  and  assure  that 
medication  interactions  and  the  use  of 


The  following  discussion  is  a  brief  overview  of 
tailored  treatment  approaches  for  special  populations 
and  is  not  an  exhaustive  or  definitive  account  of  all 
possible  treatments  of  this  nature.  More  research  is 
needed  to  identity  the  best  treatment  approaches  for 
the  special  populations  discussed  in  this  chapter  as 
well  as  for  others  not  included  here. 
f  See  Chapter  III. 


-119- 


potentially  addictive  medications  are  considered 
and  monitored.5 

For  example,  patients  treated  with  opioids  for 
pain  may  be  at  risk  for  developing  addiction, 
particularly  if  they  do  not  take  them  as 
prescribed.6  Likewise,  the  frequent  use  of 
addictive  substances  such  as  cocaine  can  result 
in  a  range  of  gastrointestinal  and  cardiac 
complications  that  can  affect  various  organs  in 
the  body;  medications  used  in  detoxification  and 
addiction  treatment  may  further  complicate  these 
medical  conditions.7 

The  efficacy  of  particular  addiction  treatment 
approaches  has  not  been  examined 
systematically  in  patient  populations  with  co- 
occurring  medical  conditions.  However, 
medical  and  other  health  professionals  should 
plan  carefully  the  treatment  protocols  for 
patients  with  co-occurring  addiction  and  other 
medical  conditions,  be  prepared  to  monitor  and 
address  emergent  reactions  that  may  arise  in  the 
course  of  treating  these  patients  and  consult  with 
specialists  in  other  medical  sub-specialties  when 
necessary.8 

Co-occurring  Mental  Health 
Disorders* 

In  the  late  1 970s,  treatment  professionals  began 
to  recognize  the  effect  that  co-occurring  mental 
health  disorders  had  on  patients'  success  in 
addiction  treatment.  Around  the  same  time, 
treatment  professionals  and  programs  began  to 
document  the  large  number  of  addiction  and 
mental  health  treatment  seekers  suffering  from 
both  sets  of  problems/  9 

Traditionally,  patients  with  co-occurring 
addiction  and  mental  health  disorders  were  sent 
to  one  treatment  setting  or  another  to  address 
their  problems  sequentially.10  Patients  have 


The  treatment  programs  discussed  in  this  section 
represent  the  main  evidence-based  treatment 
modalities  for  individuals  with  co-occurring 
addiction  and  mental  health  disorders.  It  is  not  a 
comprehensive  list  of  available  programs. 
*  See  Chapter  III  for  data  on  the  prevalence  of  co- 
occurring  addiction  and  mental  health  disorders. 


been  advised  either  to  "solve"  their  addiction 
problems  before  entering  mental  health 
treatment  or  stabilize  their  mental  health 
problems  before  entering  addiction  treatment.11 
This  approach  has  not  been  effective  since  each 
condition  tends  to  exacerbate  the  other.12 

Current  standards  call  for  treatment  programs 
serving  patients  with  addiction  and  mental 
health  disorders  to  provide  integrated  care  that 
treats  both  conditions  simultaneously.13 
Treatment  providers  may  coordinate  addiction 
and  mental  health  treatment  services  by 
combining  therapies  or  by  managing  the  care 
while  patients  receive  both  types  of  treatments 
concurrently. 14 


Integrating  addiction  treatment  and  mental 
health  care  for  patients  with  co-occurring 
disorders  increases  retention  and  yields  positive 
outcomes,  including  higher  abstinence  rates  and 
reduced  hospitalization  and  arrest  rates.16 
Integrated  treatment  also  helps  providers  prevent 
adverse  drug  interactions  among  their  patients 
and  ensure  that  proper  medication  dosage  is  used 
to  treat  both  conditions.17 


Essential  Program  Components  and 
Principles  for  Treating  Patients  with 
Co-occurring  Disorders15 

•  Coordinated  treatment  and  recovery  plan; 

•  Access  to  addiction  and  regular  medical  and 
mental  health  services  within  the  same 
facility  or  through  collaborating  programs; 

•  Specialists  to  provide  addiction  treatment, 
psychiatric  services  and  other  health  care 
services  as  needed; 

•  Patient  information  about  the  nature  of  the 
disorders,  the  importance  of  lifestyle 
changes  and  adherence  to  treatment 
regimens  and  strategies  for  relapse 
prevention; 

•  Comprehensive  support  services  to  address 
issues  such  as  housing  and  unemployment; 

•  Access  to  mutual  support  programming;  and 

•  Reintegration  of  patients  with  their  families 
and  communities. 


-120- 


Tobacco  Cessation 

Smoking  rates  are  high  among  individuals  with 
mental  health  disorders,  due  to  common 
neurobiological  and  psychosocial  risk  factors, 
the  tendency  to  smoke  as  a  means  of  self- 
medication  and  a  reduced  ability  to  manage  the 
difficult  process  of  cessation.18 

Practice  guidelines  for  smoking  cessation 
underscore  the  importance  of  providing  smoking 
cessation  services  to  patients  with  co-occurring 
mental  health  disorders,  utilizing  motivational 
and  cognitive-behavioral  approaches  and 
combining  psychosocial  therapies  with 
pharmaceutical  interventions-practices  that 
mirror  those  that  are  recommended  for  the 
general  population.19  However,  in  implementing 
these  approaches,  care  must  be  taken  to  ensure 
that  interventions  are  tailored  to  the  clinical 
needs  of  the  patient  and  that  such  interventions 
do  not  contraindicate  other  treatments  the  patient 
might  be  receiving  for  his  or  her  mental  illness.20 

Bupropion  has  been  approved  by  the  FDA  as 
both  a  smoking  cessation  medication  and  an 
antidepressant,  making  it  uniquely  suited  to  treat 
individuals  with  co-occurring  mood  disorders 
and  addiction  involving  nicotine.21  Preliminary 
findings  indicate  that  use  of  bupropion,  in 
conjunction  with  nicotine  replacement  therapy 
(NRT),  can  be  particularly  helpful  in  treating 
patients  with  co-occurring  mental  health 
disorders.22  However,  research  on  smoking 
cessation  interventions  in  populations  with  co- 
occurring  mental  health  disorders  is  very 
limited,  in  part  because  patients  with  such 
disorders  historically  have  been  excluded  from 
many  smoking  cessation  studies.23 

Monitoring  a  patient's  smoking  and  cessation 
activities  is  extremely  important  for  those  with 
mental  illnesses  since  tobacco  use  can  affect  the 
treatment  of  mental  health  disorders.24  For 
example,  because  smoking  may  influence  the 
metabolism  of  certain  commonly  prescribed 
psychiatric  medications,  dosages  of  these 
medications  may  need  to  be  adjusted  when  a 


Smokers  typically  need  twice  the  dosage  of  these 
medications  than  nonsmokers. 


patient  is  cutting  back  or  quitting  their  ingestion 
of  tobacco  products.25 

Treatment  for  Addiction  Involving  Alcohol 
and  Other  Drugs 

Psychosocial  interventions  have  proven  effective 
for  patients  with  co-occurring  mental  health 
disorders  and  addiction.26  Patients  with  co- 
occurring  schizophrenia  and  addiction  appear  to 
respond  positively  to  psychosocial  approaches 
that  include  cognitive  behavioral  therapy  (CBT), 
motivational  interviewing  (MI)  and  family 
therapy  components.27  Patients  with  co- 
occurring  addiction  and  mood  disorders  respond 
well  to  behavioral  skills  training.*  28  Integrated 
group  therapy  (IGT),  a  CBT-based  intervention 
for  co-occurring  addiction  and  bipolar  disorders, 
was  found  to  be  significantly  more  beneficial 
than  a  standard  group  therapy  program:  in  one 
study,  IGT  patients  used  alcohol  and  other  drugs 
half  as  often  as  other  patients  did  during  the 
intervention  and  three  months  after  treatment.29 

There  also  is  evidence  of  the  efficacy  of 
pharmaceutical  interventions  for  patients  with 
co-occurring  disorders.30  Antidepressants, 
including  selective  serotonin  reuptake  inhibitors 
(SSRIs),  are  an  effective  pharmaceutical 
treatment  for  many  individuals  with  co- 
occurring  mood  disorders  and  addiction 
involving  alcohol31  and  may  be  effective  for 
patients  with  co-occurring  mental  health 
disorders  and  addiction  involving  opioids  or 
sedatives  as  well.  Stimulating  antidepressants, 
such  as  desipramine  or  bupropion,  may  be  more 
useful  for  treating  patients  with  co-occurring 
depression  and  addiction  involving  cocaine.32 
Preliminary  research  also  suggests  that  certain 
anticonvulsant  medications  may  be  effective  in 
treating  patients  with  co-occurring  mood  or 
anxiety  disorders  and  addiction  involving 
alcohol.33 


1  The  behavioral  skills  training  model  utilized  a 
psycho-educational  approach  to  teach  patients  self- 
management  skills  and  provide  opportunities  for 
practice. 


-121- 


While  evidence  regarding  effective  treatments 
for  addiction  and  co-occurring  trauma  disorders 
is  limited,  psychotherapeutic  approaches, 
typically  involving  CBT  and  a 
psychoeducational  component,  appear  to  be 
quite  effective.34 


Adolescents 

Treatment  approaches  for  adolescents  must  be 
tailored  to  the  profound  neurochemical, 
physical,  cognitive,  emotional  and  social 
changes  that  take  place  during  adolescent 
development  and  to  the  heightened  influence  of 
family  and  peers  relative  to  adult  patients.41 
Because  early  initiation  of  substance  use  is 
related  so  strongly  to  the  risk  of  addiction,42 
interventions  for  young  people  demonstrating 
early  signs  of  risky  substance  use  and  treatment 
for  addiction  is  imperative.43  Treatment 
approaches  with  a  strong  evidence  base  in  adult 
populations  are  not  necessarily  applicable  to  the 
treatment  needs  of  adolescents  with  addiction.44 

The  clinical  presentation  of  addiction  often 
differs  in  adolescents  compared  to  adults: 
adolescents  typically  do  not  demonstrate  the 
same  extent  of  physical  dependence  (i.e., 
tolerance  and  withdrawal)  symptoms; 
progression  from  use  to  addiction  often  is  more 
rapid;  and  co-occurrence  with  mental  health 
disorders  is  more  common.45 

Treatment  programs  for  adolescents  should  be 
developmentally  appropriate  and  family 
oriented.46  Special  care  should  be  taken  when 
providing  group-based  therapy  to  adolescents 
who  may  be  more  vulnerable  than  adults  to 
potential  negative  peer  influences;  this  is 
especially  true  when  the  group  contains 
members  with  significant  behavioral  problems.47 
A  significant  proportion  of  adolescents  with 
addiction  have  histories  of  trauma  or  adverse  life 
experiences  as  well  as  co-occurring  disorders 
that  must  be  addressed  in  treatment.48 

Tobacco  Cessation 

A  range  of  effective  options  exists  for  teen 
smoking  cessation,  including  NRT,49  educational 
programs  that  offer  life-skills  training  and 
counseling  interventions.50  A  meta-analysis  of 
48  smoking  cessation  program  studies  from 
1970  to  2003  for  adolescents  ages  12-19  found 
that  the  odds  of  quitting  for  smokers  in  these 
programs  increased  by  46  percent.  Higher  quit 
rates  were  found  in  programs  that  included 


Integrated  Treatment  for 
Co-occurring  Disorders 

Originally  developed  to  treat  patients  with  a 
serious  mental  illness,  Assertive  Community 
Treatment  (ACT)  was  modified  in  the  late  1990s 
to  serve  patients  with  co-occurring  addiction  and 
mental  health  disorders.35  The  ACT  model  is  an 
effective  way  of  delivering  integrated  dual 
disorders  treatment  (IDDT),  also  known  as 
integrated  treatment  for  co-occurring  disorders. 
This  integrated  approach  to  treatment  for  people 
with  mental  illness  and  addiction  should  include 
the  following  components:  staged  interventions, 
assertive  outreach,  motivational  interventions, 
counseling,  social  support  interventions,  a  long- 
term  perspective  to  treatment,  comprehensiveness 
and  cultural  sensitivity  and  competence.36  The 
approach  relies  on  a  multidisciplinary  team  of 
providers  and  intensive  outreach  activities- 
including  providing  services  to  patients  in  their 
homes  and  communities— to  keep  participants 
actively  engaged  in  a  high-intensity  outpatient 
treatment  model.37  The  services  provided 
combine  treatment  approaches  such  as 
motivational  interviewing  (MI)  or  cognitive 
behavior  therapy  (CBT)  with  support  services 
such  as  psycho-educational  instruction  about 
addiction,  12-step  mutual  support  programming 
and  life  skills  training.38  Patients  are  monitored 
closely  and  have  access  to  crisis  intervention 
services  24  hours  a  day.39 

Participation  in  this  type  of  program  is  associated 
with  reduced  alcohol  and  other  drug  use  (based  on 
clinicians'  reports),  reduced  hospital  utilization, 
lower  post-treatment  relapse  rates  and  improved 
quality  of  life.40 


-122- 


motivational-enhancement  therapy  (MET),  CBT 
and  social  influence  approaches  in  which 
adolescents  address  the  influences  that  promote 
or  maintain  smoking  behavior.51 

Treatment  for  Addiction  Involving  Alcohol 
and  Other  Drugs 

Psychosocial  therapies  such  as  CBT52  and 
family-based  therapies  are  effective  treatments 
for  adolescents  with  addiction.53  Interventions 
that  integrate  a  family  component  into 
psychosocial  interventions  are  particularly 
effective  for  adolescent  patients.54  Adolescents 
generally  seem  to  fare  better  in  treatment 
programs  that  include  family  members  in 
counseling  sessions  or  that  encourage  families  to 
take  an  active  role  in  the  treatment  process.55 

Particular  types  of  family-based  therapies  that 
have  proven  effective  for  adolescents  include: 

•  Multidimensional  Family  Therapy  (MDFT)-- 
an  outpatient  family-based  treatment  program 
that  addresses  adolescent  alcohol  and  other 
drug  use  in  relation  to  individual-,  family-, 
peer-  and  community-level  influences.56  One 
study  found  that  adolescents  who  received 
MDFT  were  likelier  than  those  who  received 
other  interventions,  such  as  group  therapy  or 
educational  interventions,  to  complete  their 
treatment  and  to  demonstrate  reduced  alcohol 
and  other  drug  use  directly  following 
treatment  and  one  year  later.57 

•  Functional  Family  Therapy  (FFT)--a 
comprehensive  approach  to  treatment 
implemented  in  the  home  or  in  clinical  or 
school  settings  based  on  the  idea  that 
behaviors  influence  and  are  influenced  by 
multiple  systems  in  the  adolescent's  life, 
including  the  family.  The  three-month 
program  consists  of  engaging  and 
motivating  adolescents  and  families;  the 
development  and  implementation  of  an 
individually  tailored,  long-term  behavior 
change  plan;  and  an  attempt  to  generalize 
positive  behavior  change  to  other  areas  of 
family  functioning.  Research  suggests  that 
interventions  that  include  FFT  produce 


better  treatment  outcomes  than  those 
without  an  FFT  component.58 

You  have  an  addicted  family  system.  The  family 
needs  education  and  therapy,  especially  with 
adolescents  in  treatment.59 

-John  Coppola 
Executive  Director 
New  York  Association  of  Alcoholism  and 
Substance  Abuse  Providers,  Inc.  (ASAP) 

...It  is  clear  the  family  plays  an  important  role  in 
encouraging  and  supporting  recovery,  especially 
in  adolescents.60 

-Jose  Szapocznik,  PhD 
Professor  and  Chair, 
Department  of  Epidemiology  and  Public  Health 
Director,  Center  for  Family  Studies 
Director, 
Miami  Clinical 
Translational  Science  Institute 


•    Multi-Systemic  Therapy  (MST)-a  family- 
based  approach  to  addressing  risk  factors 
associated  with  serious  antisocial  behavior 
in  children  and  adolescents  who  use  alcohol 
or  other  drugs.  The  treatment  generally 
takes  place  in  familiar  environments  (homes, 
schools  or  other  neighborhood  settings) 
which  contributes  to  a  high  retention  rate.61 
In  addition  to  addressing  substance  use, 
MST  also  attempts  to  reduce  criminal  and 
other  forms  of  problem  behavior  and 
decrease  future  involvement  with  juvenile 
justice  and  child  welfare  systems.62  MST  is 
associated  with  reduced  alcohol  and  other 
drug  use  during  treatment  and  for  at  least  six 
months  following  program  completion,63 
and  is  particularly  effective  for  those 
involved  with  the  juvenile  justice  system.64 

A  large  study  of  adolescent  treatment 
participants  in  different  types  of  programs 
found  that  in  the  year  following  treatment,  the 
percentage  of  adolescents  using  marijuana  at 
least  weekly  was  cut  by  approximately  half. 


The  study  included  more  than  1,100  adolescent 
treatment  participants  from  23  different  programs  in 
four  cities. 


-123- 


Heavy  drinking  rates  fell  from  33.8  percent  to 
20.3  percent.  The  rate  of  criminal  activity  also 
declined  and  indicators  of  psychosocial 
adjustment,  school  attendance  and  academic 
performance  improved  significantly.65 

As  is  true  for  adults,  comprehensive  and 
continuing  care  is  critical  for  adolescents  with 
addiction.  Assertive  continuing  care  (ACC)  is  a 
method  of  enhancing  engagement  in  treatment 
by  moving  responsibility  for  service  utilization 
from  adolescents  and  their  caregivers  to 
treatment  providers.66  ACC  is  characterized  by 
at  least  weekly  face-to-face  sessions  conducted 
in  the  home  or  community  settings  that  are 
convenient  for  the  adolescent  and  increase  the 
likelihood  of  retention  and  low  patient-to- 
provider  ratios.  Interventions  used  in  ACC 
include  an  adolescent-oriented  community 
reinforcement  approach  (A-CRA)  and  intensive 
case  management.67  Research  on  this  approach 
demonstrates  that  adolescents  receiving  ACC 
were  significantly  likelier  to  be  abstinent  from 
marijuana  following  discharge  from  residential 
treatment  than  adolescents  who  did  not  receive 
ACC;*  they  also  had  higher  rates  of  retention  in 
aftercare  services.68 

Very  few  studies  have  examined  the  use  and 
effectiveness  of  pharmaceutical  interventions  for 
the  treatment  of  adolescent  patients  with 
addiction  involving  alcohol  or  other  drugs;69  best 
practice  suggests  that  if  they  are  employed  they 
should  be  used  as  a  supplement  to  psychosocial 
therapies.70 

Women 

A  considerable  body  of  evidence  demonstrates 
the  importance  of  addressing  gender  differences 
in  the  treatment  process,  particularly  for  women 
with  histories  of  trauma  and  those  who  are 
pregnant  or  parenting.71  Women  often  smoke, 
drink  and  use  other  drugs  for  different  reasons 
than  men  and  addictive  substances  affect  women 


All  participants  received  referrals  to  adolescent 
outpatient  treatment  providers  for  continuing  care  in 
their  communities  following  discharge  from 
residential  treatment. 


differently  than  men;  this  may  indicate  different 
treatment  needs.72  Because  the  life  roles  and 
responsibilities  of  women  typically  differ  from 
men,  their  support  service  needs  may  differ  as 
well.73  Women  with  addiction  have  high  rates 
of  co-occurring  mental  health  disorders, 
including  mood,  anxiety  and  eating  disorders 
that  should  be  addressed  in  the  treatment 
process,  and  high  rates  of  trauma  histories  that 
can  influence  treatment  outcomes.74 


Gender-specific  treatment  programs  appear  to  be 
particularly  beneficial  for  women  with  a  history 
of  sexual  abuse  and  domestic  violence.76 
Women  who  were  abused  as  children  suffer 
from  substance-related  problems  that  are  more 
severe  than  those  of  their  peers,  including 
lifetime  use  of  a  greater  number  of  substances, 
higher  alcohol  and  other  drug  severity  scores' 
and  greater  financial  and  interpersonal 
problems.77  Women  who  report  exposure  to 
physical,  sexual  or  emotional  abuse  during 
childhood  are  more  prone  to  relapse  than  other 
treatment  patients,  and  may  be  less  likely  to 
improve  during  and  after  treatment.78  Women 
with  trauma  histories  require  a  more 
empowering  and  less  confrontational  approach; 
being  told  that  they  are  powerless  over  their 
addiction-a  common  tactic  in  many  treatment 
programs  that  are  centered  on  the  12-step  model- 
-can  bring  back  feelings  of  powerlessness  from 
sexual  and  other  abuse.79 

Pregnant  Women 

Pregnant  women  require  special  consideration  in 
stabilization,  acute  treatment  and  disease 
management  protocols,  particularly  with  regard 


1  Based  on  the  Modified  Michigan  Alcohol-Drug 
Screening  Test. 


The  safety  and  security  of  'all  female ' 
[programs]  allow  women  to  disclose  things  that 
are  very  difficult  and  that  may  be  impossible 
within  a  co-ed  arrangement.  It  enhances  a 
woman's  ability  to  feel  understood  and  accepted 

75 

without  judgment,  shame  or  guilt. 


-124- 


to  pharmaceutical  interventions.  Withdrawal 
from  addictive  substances  during  detoxification 
can  be  highly  risky  to  a  fetus;  for  example, 
sudden  withdrawal  from  certain  opioids  and 
sedatives  can  lead  to  fetal  distress  or  death.81  As 
a  result,  detoxification  protocols  should  include 
careful  monitoring  of  the  pregnant  woman  and 
her  fetus  and  medical  supervision  of  the 
detoxification  process  itself— for  example, 
through  the  use  of  buprenorphine  to  treat  or 
prevent  opioid  withdrawal  during  pregnancy  '— 
preferably  under  the  direction  of  a  physician 
with  experience  in  perinatal  addiction.82 
Medically  supervised  detoxification  typically 
takes  place  during  the  second  trimester  because 
of  the  risk  of  miscarriage  in  the  first  trimester 
and  the  increased  risk  of  premature  delivery  or 
fetal  death  in  the  third  trimester.83 

Research  on  the  safety  and  efficacy  of 
pharmaceutical  therapies  for  addiction  treatment 
among  pregnant  women  is  limited.84  Certain 
medications,  such  as  disulfiram,  are  not 
considered  safe  for  pregnant  women,  while 
others,  such  as  methadone,  are  less  risky  and 
may  be  preferable  to  continued  substance  use.85 

Case  management  is  particularly  critical  for 
pregnant  women  with  addiction.86  Case 
management  services  typically  assure 
standardized  assessments,  access  to  prenatal  and 
pediatric  care,  mental  health  services,  vocational 
and  parenting  classes,  childcare  and 

87 

transportation  services. 

Pregnant  women  with  co-occurring  addiction 
and  mental  health  disorders  require  additional 
medical  monitoring  because  pregnancy  can 
aggravate  certain  symptoms  of  mental  illness, 
including  depression  and  anxiety.88  Hormonal 
changes,  increased  stress  and  pregnancy-specific 
medications  all  can  contribute  to  the  potential 
exacerbation  of  mental  illness  symptoms.89 


Specific  psychosocial  treatment  approaches  that 
work  for  pregnant  women  with  addiction  do  not 
appear  to  differ  from  those  found  to  be  effective  in 
the  general  population  of  women. 
'  Opioid  withdrawal  during  pregnancy  can  lead  to 
fetal  death. 


Although  federal  law  requires  that  pregnant 
women  receive  priority  admission  into  addiction 
treatment  programs,  allowing  them  to  bypass 
waiting  lists,90  numerous  barriers  prevent  many 
pregnant  women  from  accessing  needed 
treatment.1  While  pregnant  women  may  be 
more  motivated  than  other  women  to  receive 
addiction  treatment  because  of  the  known  risks 
of  substance  use  to  pregnant  women  and  their 
babies,  they  are  less  likely  to  stay  in  treatment 
once  admitted,  and  reductions  in  substance  use 
often  are  transient  and  dissipate  once  their 
children  are  born.91 


Older  Adults 

Treatment  approaches  for  older  adults  must  take 
into  account  their  increased  risk  of  developing 
addiction  involving  prescription  drugs  due  to  the 
use  of  medication  to  treat  chronic  pain,  sleep 
disorders,  depression  and  anxiety-problems  that 
are  common  in  this  age  group— as  well  as  the 
fact  that  their  bodies  become  even  more 
vulnerable  to  the  effects  of  alcohol  and  other 
drugs  with  age.§  94  Co-occurring  health 
conditions  and  medical  complications  due  to 
age-related  health  problems  can  interfere  with 
addiction  treatment  and  make  it  harder  for  older 
adults  to  follow  treatment  instructions  and 
plans.95 


1  See  Chapter  VII. 

§  See  Chapter  IV  for  a  discussion  of  the  unique  risks 
that  older  adults  face  with  regard  to  substance  use 
and  addiction. 


The  Center  for  Substance  Abuse  Treatment's 
(CSAT)  Pregnant  and  Postpartum  Women 
demonstration  program  provided  comprehensive 
clinical,  medical  and  social  services,  over  the 
course  of  six  to  12  months,  to  pregnant  women 
and  mothers  of  children  under  the  age  of  one.92 
During  the  six  months  following  discharge  from 
this  program,  61  percent  of  the  women  had 
achieved  and  maintained  their  abstinence  from 
alcohol  and  other  drugs.  Program  participation 
also  was  associated  with  increased  employment 
rates  and  decreased  rates  of  arrest,  foster  care 
involvement  and  premature  deliveries,  low  birth 
weight  and  infant  death. 93 


-125- 


Psychosocial  interventions,  particularly 
motivational  interviewing  (MI)  and  motivational 
enhancement  therapy  (MET),  are  regarded  as 
effective  approaches  for  older  adults,  especially 
those  who  may  resist  changing  their  substance 
use  behavior.96 

Before  prescribing  a  potentially  addictive 
medication  to  an  adult  patient,  a  full  assessment 
of  the  patient's  use  of  other  addictive  substances 
and  deliberate  counseling  with  regard  to  the 
risks  of  physical  dependence  and  the  dangers  of 
combining  addictive  substances  is  necessary. 
When  treating  older  patients  with 
pharmaceutical  therapy,  long-acting 
benzodiazepines  and  disulfiram  should  be 
avoided  because  of  their  toxicity.  Naltrexone 
has  been  tolerated  well  by  older  adults  and  there 
is  some  evidence  of  its  effectiveness  in  this 
population.97 

To  improve  treatment  compliance,  older  patients 
also  may  require  specialized  services  to  assure 
appropriate  interventions  for  dietary  deficiencies 
or  auditory  or  visual  impairments;  to  provide 
psychosocial  interventions  that  help  patients 
cope  with  loneliness,  loss  or  depression  which 
are  more  common  in  this  age  group;  and  to  help 
bolster  supportive  social  networks.98 

Racial  and  Ethnic  Minorities 

Treatment  providers  should  take  into 
consideration  the  substance-related  health 
disparities-including  the  likelihood  of  co- 
occurring  disorders— that  exist  among 
racial/ethnic  groups.* 99  Different  racial/ethnic 
groups  also  may  vary  in  their  metabolism, 
response  to  dosages  and  side  effects  of 
pharmaceutical  interventions  for  addiction.100 

While  data  are  not  available  on  specific 
psychosocial  therapies  that  work  best  for 


e.g.,  Whites  and  Hispanics  have  a  higher  severity  of 
alcohol  problems  than  other  racial/ethnic  groups  (see 
Chapter  III);  Hispanic  and  black  men  have  higher 
rates  of  cirrhosis  mortality  than  white  men;  and 
Alaska  Native  and  white  men  report  higher  rates  of 
alcohol-related  and  non-alcohol-related  major 
depressive  disorder  than  Hispanic  and  black  men. 


particular  racial/ethnic  groups,  treatment 
providers  should  ensure  that  programs  are 
effective  for  individuals  of  every  racial  and 
ethnic  background  by  making  them  sensitive  to 
racial,  ethnic  and  cultural  conditions  that  may 
affect  the  treatment  process.101  For  example, 
providers  should  make  sure  that  language 
barriers  are  addressed  and  require  cultural 
competency  training  for  staff.102  These 
measures  improve  communication  and  increase 
trust  and  understanding,  which  in  turn  result  in 
greater  recognition  of  patients'  needs,  increased 
patient  engagement  in  treatment  and  better 
treatment  compliance.103 

Individuals  of  Minority  Sexual 
Orientation 

Treatment  goals  for  lesbian,  gay,  bisexual  and 
transgender  (LGBT)  individuals  are  the  same  as 
treatment  goals  for  other  individuals  in  terms  of 
reducing  use  or  achieving  abstinence,  but 
treatment  should  also  focus  on  the  unique 
characteristics  of  LGBT  patients.  For  example, 
higher  rates  of  discrimination  against  lesbian, 
gay  and  bisexual  adults  may  be  associated  with 
higher  rates  of  risky  use  and  addiction  in  this 
population,  compared  with  heterosexuals.104 

Treatment  providers  should  screen  for  other 
health  problems  and  adverse  experiences  that 
may  be  more  common  in  the  LGBT  population 
including  co-occurring  mental  health  disorders, 
suicidal  thoughts  or  behaviors,  sexually- 
transmitted  infections  (in  particular  HIV/AIDS 
and  hepatitis  A  and  B)  and  sexual  abuse.105  Gay 
and  bisexual  men  make  up  nearly  half  of  those 
living  with  HIV  in  the  United  States;106  the 
prevalence  of  mental  health  disorders  is  higher 
among  lesbian,  gay  and  bisexual  adults'  than 
among  heterosexual  adults;1  107  and  a  review 
study  found  that  lifetime  prevalence  estimates  of 
sexual  abuse  range  from  15.6  percent  to  85.0 
percent  for  lesbian  or  bisexual  women  and  from 
11.8  percent  to  54.0  percent  for  gay  or  bisexual 


Or  those  who  report  same-sex  sexual  partners. 
Or  those  who  report  opposite-sex  sexual  partners. 


-126- 


When  assessing  available  social  support  for 
LGBT  patients,  treatment  providers  should 
recognize  that  LGBT  individuals  may 
experience  conflict  with  their  family  of  origin, 
especially  around  issues  of  sexual  orientation  or 
gender  identity,  and  it  is  important  for  treatment 
providers  to  understand  the  interpersonal 
relationships  of  their  LGBT  patients.  In 
addition,  providers  should  be  particularly  careful 
to  protect  the  confidentiality  of  LGBT  patients 
because  in  many  states  LGBT  individuals  lack 
legal  protections  against  discrimination  in 
housing,  the  job  market  or  social  services.109 

Despite  the  need  to  tailor  addiction  treatment  to 
the  needs  of  LGBT  individuals,  national  data 
show  that  only  6.2  percent  of  treatment  facilities 
offered  any  type  of  tailored  treatment 
specifically  for  LGBT  patients  in  2010.110  A 
2007  national  study  found  that  services  provided 
by  70.8  percent  of  LGBT-specialized  programs 
did  not  differ  from  services  provided  to  patients 
in  other  programs  and  only  about  seven  percent 
of  facilities  offered  LGBT-specific  services, 
such  as  special  groups  for  LGBT  patients  or 
having  counselors  who  were  trained  specifically 
in  LGBT  issues.111 

Research  evaluating  the  impact  of  treatment 
specific  to  the  needs  of  LGBT  individuals  is 
lacking.  Among  a  small  sample  of  individuals 
in  addiction  treatment,  gay  and  bisexual  men  in 
LGBT-specialized  treatment  reported  better 
outcomes,  such  as  achieving  abstinence  and 
completing  treatment,  than  gay  and  bisexual 
men  in  traditional  treatment.112 

Veterans  and  Active  Duty  Military 

The  U.S.  Department  of  Veterans  Affairs  (VA) 
and  the  Department  of  Defense  have  developed 
practice  guidelines  for  evidence-based  addiction 
treatment,  and  endorsed  the  U.S.  Public  Health 
Services'  Clinical  Practice  Guidelines  for 
smoking  cessation.113  Among  the  recommended 
practices  for  addressing  risky  use  of  addictive 
substances  and  addiction  in  veterans  and  active 
duty  members  of  the  military  are  the 
following:114 


•  Active  duty  members  involved  in  an 
incident  in  which  substance  use  is 
suspected  to  be  a  contributing  factor  are 
required  to  be  referred  to  specialty 
addiction  care  for  evaluation. 

•  A  treatment  team  shall  convene  with  the 
patient  and  command  in  order  to  review  the 
treatment  plan  and  goals. 

•  Rehabilitation  and  referral  services  for  the 
patient  require  an  individualized  plan 
designed  to  identify  the  continued  support 
of  the  patient  with  at  least  monthly 
monitoring  during  the  first  year  after 
inpatient  treatment. 

•  For  patients  who  do  not  stabilize  and  refuse 
to  engage  in  any  type  of  ongoing  care  with 
any  provider  (e.g.,  medical,  psychiatric  or 
addiction  specialty),  consider  involving 
supportive  family  members  or  significant 
others  if  the  patient  agrees.  This  may 
include  a  first  line  supervisor  when 
appropriate  and  the  unit  commander. 

Of  particular  importance  in  the  veteran  and 
active  duty  military  populations  is  the  need  to 
attend  to  co-occurring  mental  health  conditions, 
particularly  post-traumatic  stress  disorder 
(PTSD),  which  are  common  in  this 
population.115 

The  VA  has  outlined  certain  treatment 
guidelines  for  veterans  and  military  personnel 
with  addiction  and  co-occurring  PTSD,  most  of 
which  mirror  the  treatment  approaches  outlined 
in  Chapter  V  for  the  general  population. 
However,  the  VA  notes  that  treatment  for  the 
two  conditions  can  be  delivered  simultaneously, 
that  the  clinician  should  use  first-stage  treatment 
approaches  such  as  motivational  interviewing  to 
initiate  treatment  and  specifically  states  that 
tobacco  cessation  services  should  be  integrated 
into  the  treatment  protocol.116  The  most 
commonly  used  treatment  approach  for  veteran 
patients  with  co-occurring  addiction  and  PTSD 
involves  cognitive  behavioral  therapy  (CBT).117 


-127- 


The  importance  of  attending  to  co-occurring 
conditions  in  this  population  is  highlighted  by  a 
study  of  veterans  with  co-occurring  PTSD  and 
addiction  who  participated  in  addiction 
treatment*  118  This  study  found  that  receiving 
treatment  for  PTSD  during  the  initial  year  of 
addiction  treatment  almost  quadrupled 
participants'  odds  of  being  in  remission  from 
addiction^  five  years  later.119 

Individuals  Involved  in  the  Justice 
System 

In  2006,  the  National  Institute  on  Drug  Abuse 
(NIDA)  developed  evidence-based  principles  for 
the  effective  treatment  of  individuals  in  the 
justice  system  who  have  addiction.  These 
principles  include  providing  comprehensive 
assessments  of  the  extent  and  severity  of 
offenders'  substance  involvement,  addressing 
the  presence  of  co-occurring  conditions  that 
might  call  for  specialized  treatment  services, 
assessing  treatment  progress  and  adjusting 
interventions  accordingly.120 

For  both  juveniles  and  adult  offenders  with 
addiction,  the  use  of  treatment-based  alternatives 
to  incarceration  represents  an  important  step  in 
treating  the  disease.  Drug  courts,  prosecutorial- 
based  diversion  programs  and  intensive 
treatment-based  probation  are  some  of  the 
approaches  that  have  proved  effective  in  the 
justice  field.121  Services  also  can  be  provided  by 
professionals,  using  evidence  based  practices, 
during  incarceration  and  after  release.  These 
initiatives  provide  addiction  treatment,  assure 
collaboration  between  justice  authorities  and 
treatment  providers  and  hold  the  offender  legally 
accountable  for  treatment  compliance.122 


The  sample  was  drawn  from  male  inpatients 
participating  in  a  multisite  VA  program  evaluation  of 
addiction  treatment. 

'  Defined  as  having  (1)  abstained  from  all  13 
substances  investigated,  (2)  had  no  problems  related 
to  alcohol  or  other  drugs  and  (3)  consumed  3  oz. 
(88.79  ml)  or  less  of  alcohol  per  day  on  maximum 
drinking  days  in  the  past  month.  Freedom  from 
problems  related  to  substance  use  was  reflected  by  a 
response  of  "never"  to  each  of  15  problems  in  the 
areas  of  health,  work,  legal  situation  and  finances. 


Juvenile  Offenders 

Comprehensive  treatment  and  management  of 
addiction  in  the  juvenile  justice  population  result 
in  decreased  substance  use,  crime  (recidivism), 
homelessness  and  high-risk  sexual  behavior; 
improved  school  performance,  productivity, 
employment  and  future  earning  power;  and 
better  health  and  psychological  adjustment.123 

For  adolescents  in  the  juvenile  justice  system, 
screening  and  comprehensive  assessments  are 
critical  for  identifying  an  adolescent's  needs  and 
for  connecting  the  juvenile  with  effective 
interventions  and  treatments.  Comprehensive 
assessments  can  take  place  at  various  points, 
including  at  the  first  interview  after  referral  to 
juvenile  court  (often  conducted  by  an  intake 
officer)  where  results  may  be  used  to  refer  the 
adolescent  to  more  appropriate  community 
health  services  rather  than  incarceration. 
Assessments  also  may  be  conducted  upon 
admission  to  a  pre-trial  detention  center  to  await 
adjudication  or  upon  admission  to  a  post- 
adjudication  community  program  or  correctional 
facility.124 

Addiction  treatment  for  juvenile  offenders 
should  reflect  the  standards  of  evidence-based 
care  for  adolescents  in  the  general  population, 
with  a  special  focus  on  family-based  treatment 
models.  Effective  treatment  approaches  include 
multidimensional  family  therapy  (MDFT), 
functional  family  therapy  (FFT)  and  multi- 
systemic  therapy  (MST).125 

Adult  Corrections 

Treatment  tailored  to  criminal  justice 
populations  should  ensure  that  treatment  plans 
correspond  with  correctional  supervision 
requirements  as  well  as  the  medical  and  social 
support  services  that  the  patient  may  need.126 

Cognitive  behavioral  therapy  (CBT), 
motivational  enhancement  therapy  (MET)  and 
contingency  management  (CM)  have  been 
shown  to  be  effective  treatment  approaches  for 
inmates,127  particularly  in  that  they  help  train 
patients  to  recognize  errors  in  judgment  that  lead 
to  substance  use  and  to  criminal  behavior,128  and 


-128- 


help  to  increase  treatment  engagement  and 
retention.129  As  is  true  in  the  general  population, 
evidence-based  pharmaceutical  interventions 
should  be  provided  to  patients  in  the  criminal 
justice  population  along  with  psychosocial 
therapies.130 

Individuals  with  addiction  facing  release  and 
reentry  should  be  assured  appropriate  post- 
release community-based  treatment,  disease 
management  and  support  services.131 


-130- 


Chapter  VII 

The  Addiction  Treatment  Gap 


In  spite  of  the  facts  that  15.9  percent  of  the  U.S. 
population  ages  12  and  older  report  meeting 
clinical  criteria  for  addiction  and  that  evidence- 
based  interventions  and  treatments  are  widely 
available,  research  clearly  indicates  that  only  a 
small  fraction  of  those  in  need  of  addiction 
treatment  receives  it  and,  of  those  who  do,  few 
receive  evidence-based  care.  Determining  the 
exact  size  and  shape  of  the  addiction  treatment 
gap  in  this  country  is  impossible  due  to 
significant  data  limitations;*  however,  89.1 
percent  of  those  who  meet  criteria  for  addiction 
involving  alcohol  and  drugs  other  than  nicotine 
report  receiving  no  treatment f  at  all.*  1 


There  are  no  national  data  on  the  total  number  of 
people  who  receive  treatment  for  the  disease.  Rather, 
existing  data  on  addiction  treatment  exclude 
addiction  involving  nicotine,  and  data  on  the  types  of 
services  offered  and  venues  in  which  they  are 
provided  are  available  only  for  providers  that  receive 
public  funds.  Because  some  addiction  treatment 
providers  accept  both  public  and  private  funding,  the 
available  data  on  providers  serving  publicly-funded 
patients  also  include  an  unidentifiable  number  of 
patients  who  receive  private  funding. 
f  For  the  purposes  of  the  present  analyses,  treatment 
includes:  (1)  services  received  at  non-intensive  or 
intensive  non-residential  settings  (including  alcohol 
or  other  drug  rehabilitation  facilities,  mental  health 
centers  or  facilities  or  doctors'  or  mental  health 
professionals'  private  offices);  and  (2)  short-  or  long- 
term  residential  settings  (including  alcohol  or  other 
drug  rehabilitation  facilities,  hospital  or  mental  health 
centers  or  facilities)  in  the  past  12  months. 
Detoxification,  services  received  in  an  emergency 
department  or  in  prison  or  jail  settings,  mutual 
support  programs,  peer  counseling  and  other  support 
services  (including  religious-based  counseling)  are 
excluded  from  these  analyses. 
*  While  31.7  percent  of  the  U.S.  population  ages  12 
and  older  engage  in  risky  use  but  do  not  meet  criteria 
for  addiction,  there  has  been  no  attempt  to  document 
nationally  the  proportion  of  this  population  that 
receives  evidence-based  screening  and  brief 
interventions,  leaving  the  size  of  the  intervention  gap 
for  risky  users  unknown.  Therefore,  this  chapter 
focuses  exclusively  on  the  treatment  gap  for 
individuals  with  addiction. 


-131- 


Of  those  whose  addiction  involves  nicotine,  the 
only  data  available  are  for  persons  ages  1 8  and 
older  who  have  tried  to  quit  smoking;  less  than 
one-third  (31.7  percent)  of  these  individuals 
receive  smoking  cessation  services.1  2 

A  key  factor  contributing  to  the  treatment  gap  is 
the  way  treatment  costs  are  covered.  In  contrast 
to  the  role  of  private  insurance  in  medical  care 
spending-where  it  covers  55.6  percent  of 
costs,  private  insurers  cover  only  20.8  percent  of 
the  costs  of  addiction  treatment,  and  the  private 
share  has  been  decreasing.  Instead,  public 
spending  accounts  for  79.2  percent  of  the  costs 
of  addiction  treatment  in  the  United  States.3 
This  skewing  of  services  to  populations 
dependent  on  public  resources  is  in  part  a  result 
of  our  failure  to  prevent  and  treat  this  disease. 
Public  spending  also  has  concentrated  available 
resources  for  treatment  in  non-residential 
services  operated  outside  of  the  mainstream 
health  care  system.  In  both  public  and  private 
plans,  insurance  coverage  for  addiction  care  has 
been  limited  in  the  range  of  covered  services.4 

National  data  indicate  that  people  in  need  of 
help  for  addiction  largely  choose  to  turn  to  a 
health  professional;  however,  only  5.7  percent  of 
referrals  to  addiction  treatment  come  from 
health  professionals.  The  largest  share  of 
referrals— 44.3  percent— comes  from  the  criminal 
justice  system,5  demonstrating  our  nation's 
attention  to  the  social  consequences  of  addiction 
rather  than  to  prevention  and  treatment  of  the 
disease.  Even  those  who  are  referred  to 
treatment  may  face  long  waits  for  admission  and 
the  longer  the  wait  the  less  likely  patients  are  to 
enter  or  complete  treatment.6 

Only  42. 1  percent  of  those  receiving  treatment 
for  addiction  involving  alcohol  or  drugs  other 
than  nicotine  complete  their  course  of  care.7 
The  highest  treatment  completion  rates  are  from 
venues  to  which  there  are  the  least  referrals- 
residential  treatment;  the  lowest  treatment 


Among  current  smokers  who  tried  to  quit  in  the  past 
year  and  former  smokers  who  successfully  quit  in  the 
past  two  years. 

f  In  the  form  of  counseling  or  smoking  cessation 
medications. 


completion  rates  are  from  venues  to  which  there 
are  the  most  referrals-non-residential 
treatment.8 

A  range  of  factors  contribute  to  these  spending, 
referral  and  service  delivery  patterns  that 
account  for  the  treatment  gap,  including  a 
misunderstanding  of  the  disease  of  addiction,  a 
lack  of  appropriate  disease  staging  and  treatment 
services,1  negative  public  attitudes  and  behavior 
toward  those  with  the  disease,  privacy  concerns, 
cost,  lack  of  information  on  how  to  get  help, 
limited  availability  of  services  including  a  lack 
of  trained  addiction  physician  specialists, 
insufficient  social  support,  conflicting  time 
commitments,  negative  perceptions  of  the 
treatment  process  and  legal  barriers.  Certain 
populations  with  addiction,  including  those  with 
co-occurring  health  conditions,  pregnant  and 
parenting  women,  adolescents,  older  adults,  the 
homeless,  veterans  and  those  in  active  duty 
military,  individuals  living  in  rural  areas  and 
Native  Americans,  face  additional  barriers. 

This  chapter  examines  the  disconnect  between 
those  in  need  of  treatment  and  those  who  receive 
it.  The  fact  that  those  who  do  receive  some  form 
of  treatment  rarely  receive  quality,  evidence- 
based  care  is  discussed  in  Chapter  X. 


1  See  Chapter  X. 

-132- 


Most  People  in  Need  of  Treatment 
Do  Not  Receive  It 

In  2010,  15.9  percent  of  the  U.S.  population 
ages  12  and  older-40.3  million  people-met 
diagnostic  criteria  for  addiction.  Although 
some  treatment  providers  are  beginning  to 
address  the  disease  of  addiction 
comprehensively,  including  all  involved 
substances,  no  single  national  data  source  exists 
to  compare  the  proportion  of  the  population  in 
need  of  addiction  treatment'  involving  any 
addictive  substance  (including  nicotine)  to  the 
proportion  that  receives  such  treatment.  CASA 
Columbia's  analysis  of  the  treatment  gap  in  the 
following  discussion,  therefore,  is  based  on 
available  data  and  limited  to  the  9.1  percent 
(23.2  million)  whose  addiction  involves  alcohol 
or  other  drugs  excluding  nicotine. i  9 

CASA  Columbia's  analysis  indicates  that  only 
one  in  10  (10.9  percent,  2.5  million)  of  those  in 
need  of  addiction  treatment  (excluding  nicotine) 
receive  it,  leaving  a  treatment  gap  of  20.7 
million  individuals.  The  proportion  of 
individuals  in  need  of  addiction  treatment  who 
actually  receive  it  has  changed  little  since  2002, 
when  9.8  percent  of  those  in  need  received  it.10 
This  is  in  stark  contrast  to  the  much  smaller 


treatment  gaps  that  exist  for  other  major  health 
conditions  including  hypertension,  diabetes  and 
major  depression.5  11 
(Figure  7  A) 


Figure  7. A 

Individuals  with  Select  Medical  Conditions 
Who  Receive  Treatment 


Hypertension1 


Diabetes2 


Major 
Depression3 


Addiction3 
(excluding 
Nicotine*) 


1  Ages  18  and  older;  Ostchega,  Y.,  Yoon,  S.S.,  Hughes,  J.  &  Louis,  T. 
(2008). 

2  All  ages;  Centers  for  Disease  Control  and  Prevention.  (201 1). 

3  Ages  1 2  and  older;  CASA  Columbia  analysis  of  The  National  Survey 
on  Drug  Use  and  Health  (NSDUH),  201 0 

*  Due  to  data  limitations. 


Those  meeting  criteria  for  addiction  include 
individuals  who  met  the  Nicotine  Dependence 
Syndrome  Scale  (NDSS)  criteria  for  past  month 
nicotine  dependence,  or  the  DSM-IV  clinical 
diagnostic  criteria  for  past  year  alcohol  and/or  other 
drug  abuse  or  dependence.  This  estimate  excludes 
the  institutionalized  population,  for  which  rates  of 
addiction  are  higher. 

'  Those  in  need  of  treatment  are  defined  not  only  as 
those  who  met  DSM-IV  diagnostic  criteria  for  past 
year  alcohol  and/or  other  drug  abuse  or  dependence, 
but  also  those  who  have  received  formal  treatment 
for  addiction  involving  alcohol  and/or  other  drugs  in 
the  past  year.  Due  to  data  limitations,  individuals  in 
need  of  treatment  for  addiction  involving  nicotine  are 
not  included  in  this  analysis. 
*  Another  nine  percent  (22.9  million)  of  the 
population  has  addiction  involving  nicotine;  2.7 
percent  of  the  population  (7.0  million)  has  addiction 
involving  multiple  substances,  including  alcohol, 
illicit  drugs,  controlled  prescription  drugs  and/or 
nicotine. 


s  For  this  comparison,  CASA  Columbia  examined  the 
referenced  national  survey  data  to  determine  the 
proportion  of  the  population  with  each  disease— those 
with  diagnosed  or  undiagnosed  hypertension  (59.3 
million);  those  with  diagnosed  or  undiagnosed 
diabetes  (25.8  million);  those  who  met  clinical 
criteria  for  a  major  depressive  episode  in  the  past 
year  and/or  received  professional  treatment  (saw  a 
doctor,  received  medication,  some  combination 
thereof)  (22.4  million);  and  those  who  met  clinical 
criteria  for  addiction  involving  alcohol  or  other  drugs 
excluding  nicotine  in  the  past  year  and/or  received 
professional  treatment  for  alcohol  and/or  other  drugs 
in  the  past  year  (23.2  million)— who  received 
treatment. 


-133- 


Other  national  data  indicate  that,  in  2010  among 
smokers  age  18  and  older,  68.8  percent  tried  to 
stop  smoking*  but  only  31.7  percent  of  those 
who  tried  to  stop  received  some  type  of  smoking 
cessation  service  (psychosocial  or 
pharmaceutical  treatment).^  12 

Variations  in  the  Treatment  Gap  by 
Primary  Substance  Involved 

In  2010,  7.4  percent  of  the  population  needed 
treatment  for  addiction  involving  alcohol*  and 
3.1  percent  needed  treatment  for  addiction 
involving  another  drug  (excluding  nicotine);5  1.3 
percent  of  the  total  population  needed  treatment 
for  addiction  involving  multiple  substances, 
excluding  nicotine."  While  considerably  more 
people  needed  treatment  for  addiction  involving 
alcohol  (18.7  million)  compared  to  those 
needing  treatment  for  addiction  involving  an 
illicit  or  controlled  prescription  drug  (7.9 
million)  or  multiple  substances  (3.4  million),11  13 
they  were  less  likely  to  receive  it: 

•     8.8  percent  (1.7  million)  of  those  in  need  of 
treatment  for  addiction  involving  alcohol 
received  it,  leaving  a  treatment  gap  of  17.1 
million  people; 


The  source  of  these  data  does  not  present  the 
proportion  of  the  sample  that  smoked,  just  the 
proportion  of  smokers  that  tried  to  quit. 
'  Among  current  smokers  who  tried  to  quit  in  the  past 
year  and  former  smokers  who  successfully  quit  in  the 
past  two  years.  Trend  data  are  not  available  for  these 
measures. 

*  18.1  percent  of  these  individuals  also  needed 
treatment  for  addiction  involving  other  drugs. 
§  43.1  percent  of  these  individuals  also  needed 
treatment  for  addiction  involving  other  drugs, 
excluding  nicotine. 

The  7.4  percent  of  those  needing  treatment  for 
addiction  involving  alcohol  and  the  3.1  percent 
needing  treatment  for  addiction  involving  other  drugs 
overlap  with  the  category  needing  treatment  for 
multiple  substances.  Looking  at  mutually  exclusive 
categories,  6.0  percent  needed  treatment  for  addiction 
involving  alcohol  only  and  1.8  percent  needed 
treatment  for  addiction  involving  other  drugs 
(excluding  nicotine)  only. 
1  f  Individuals  in  need  of  treatment  for  addiction 
involving  multiple  substances  also  are  included  in  the 
other  two  categories. 


19.9  percent  (1.6  million)  of  those  in  need  of 
treatment  for  addiction  involving  another 
drug  (excluding  nicotine)  received  it, 
leaving  a  treatment  gap  of  6.3  million 
people;  and 

28.5  percent  (1.0  million)  of  those  in  need  of 
treatment  for  addiction  involving  multiple 
substances  (excluding  nicotine)  received  it, 
leaving  a  treatment  gap  of  2.4  million 
people.14  (Figure  7.B) 


Figure  7.B 

The  Treatment  Gap: 
Need  for  Addiction  Treatment 
and  Receipt  of  Needed  Services 
(Excluding  Nicotine),  2010 


18.7M 


I  Need  for  Treatment 
i  Receipt  of  Treatment 


7.9M 


1.6M 


3.4M 


1.0M 


Alcohol 


Other  Drugs 


Multiple  Substances 


Note:  Individuals  who  need  and/or  receive  treatment  for  addiction 
involving  multiple  substances  also  are  included  in  the  other  two 
categories. 

Source:  CASA  Columbia  analysis  of  The  National  Survey  on  Drug 
Use  and  Health  (NSDUH),  2010. 


Of  the  3 1 .7  percent  of  those  ages  1 8  and  older 
who  wanted  to  stop  smoking  in  2010,  5.9 
percent  received  cessation  counseling**  and  30.0 
percent  received  medications;55  4.3  percent 
received  both.15 


++  3. 1  percent  used  a  telephone  quitline,  2.6  percent 
received  one-on-one  counseling  and  2.4  percent  were 
involved  in  a  stop  smoking  clinic,  class  or  support 
group. 

§§  14.6  percent  used  the  nicotine  patch,  1 1.2  percent 
used  the  medication  varenicline,  8.9  percent  used  the 
nicotine  gum  or  lozenge,  3.2  percent  used  the 
medication  bupropion  and  1 .0  percent  used  the 
nicotine  spray/ inhaler. 


-134- 


Variations  in  the  Treatment  Gap  by  Key 
Patient  Characteristics 

The  addiction  treatment  gap  is  substantial  across 
all  demographic  groups,  with  the  greatest  need 
among  adolescents,  young  adults  and 
Hispanics.16 

Gender.  In  20 1 0,  twice  as  many  males  as 
females  were  in  need  of  addiction  treatment 
(12.2  percent  vs.  6.2  percent).17  That  year: 

•  10.5  percent  of  males  in  need  of  treatment 
received  it,  leaving  a  treatment  gap  of  13.5 
million;  and 

•  11.7  percent  of  females  in  need  of  treatment 
received  it,  leaving  a  treatment  gap  of  7.2 
million.18 

Although  more  males  than  females  had 
addiction  involving  nicotine  in  2010  (9.9  percent 
vs.  8.2  percent),19  more  female  than  male 
smokers  were  interested  in  quitting  (70.7  percent 
vs.  67.3  percent)  and  treatment  was  more 
prevalent  among  females  than  among  males 
(35.1  percent  vs.  28.8  percent).20 

Age.  In  2010,  young  people  ages  18  to  25  were 
the  most  likely  of  all  age  groups  to  need 
addiction  treatment: 

•  7.5  percent  of  teens  ages  12  to  17  and  20.5 
percent  of  young  adults  ages  1 8  to  25  were 
in  need  of  treatment  (15.1  percent  of  all  12 
to  25  year  olds)  but  only  1 . 1  percent  of  all 
12  to  25  year  olds  received  it,*  leaving  a 
treatment  gap  of  8.2  million;  and 

•  7.4  percent  of  adults  ages  26  and  older  were 
in  need  of  treatment  but  only  1.0  percent 
received  it,  leaving  a  treatment  gap  of  12.5 
million.21 


Although  more  18-  to  25-year  olds  than  adults 
ages  26  and  older  had  addiction  involving 
nicotine  (10.4  percent  vs.  9.7  percent)  in  20 10,22 
those  ages  26  and  older^  were  more  likely  to  be 
interested  in  quitting,  and  smoking  cessation 
treatment  was  higher  among  those  ages  25  and 
older  (29.4  percent  of  25-  to  44-year  olds;  42.3 
percent  of  45-to  64-year  olds;  and  35.9  percent 
of  those  ages  65  and  older)  than  among  18-  to 
24-year  olds  (15.8  percent).23 

Race/Ethnicity.  Similar  to  racial/ethnic 
disparities  that  have  been  found  for  other  health 
conditions,24  Hispanics  were  slightly  likelier 
than  white  or  black  people  to  need  addiction 
treatment  (10.1  percent  vs.  9.3  percent  and  8.8 
percent,  respectively)  but  less  likely  to  receive  it 
in2010:25 

•  7.0  percent  of  Hispanics  in  need  of  treatment 
received  it,  leaving  a  treatment  gap  of  3.5 
million; 

•  11.7  percent  of  whites  in  need  of  treatment 
received  it,  leaving  a  treatment  gap  of  13.9 
million;  and 

•  11.9  percent  of  blacks  in  need  of  treatment 
received  it,  leaving  a  treatment  gap  of  2.4 
million/26 

Whites  were  likelier  than  blacks  or  Hispanics  to 
have  addiction  involving  nicotine  (10.9  percent 
vs.  6.9  percent  and  4.2  percent,  respectively),27 
but  adult  black  smokers  were  likelier  than  adult 
white  and  Hispanic  smokers  to  be  interested  in 
quitting  in  2010  (75.6  percent  vs.  69.1  percent 
and  61.0  percent,  respectively).  White  smokers, 
however,  were  likelier  to  use  smoking  cessation 
treatments  than  black  or  Hispanic  smokers  (36.1 
percent  vs.  21.6  percent  and  15.9  percent, 
respectively).28  Other  research  supports  the 


1  Interest  in  quitting  was  higher  among  adults  ages  25 
to  44  (72.5  percent)  and  ages  45  to  64  (69.0  percent) 
relative  to  those  ages  18  to  24  (66.7  percent);  older 
adults  ages  65  and  older  were  the  least  interested  in 
quitting  (53.8  percent). 

*  A  recent  study  found  that  black  and  Hispanic 
adolescents  are  significantly  less  likely  to  receive 
addiction  treatment  relative  to  white  adolescents. 


The  sample  sizes  for  those  who  received  needed 
treatment  is  too  small  to  report  statistically  reliable 
data  for  12-  to  17-year  olds  and  18-  to  25-year  olds 
separately. 

-135- 


finding  that  black  and  Hispanic  smokers  are  less 
likely  than  white  smokers  to  use  smoking 
cessation  interventions  such  as  nicotine 
replacement  therapy  (NRT)  and  other 
pharmaceutical  therapies.29 

Special  Populations.  The  need  for  addiction 
treatment  is  disproportionately  higher  for 
individuals  with  co-occurring  mental  health 
disorders,  for  individuals  involved  in  the  justice 
system  and  for  members  of  the  military, 
including  veterans,  returning  from  active  combat 
in  Iraq  and  Afghanistan: 

•  In  2010,  one  in  five  (20.7  percent)  non- 
institutionalized  individuals  ages  1 8  and 
older*  with  a  diagnosed  mental  health 
disorder'  were  in  need  of  addiction 
treatment  (relative  to  6.3  percent  of  those 
without  a  diagnosed  mental  health  disorder); 
14.2  percent  of  those  in  need  of  addiction 
treatment  received  it,  leaving  a  treatment 
gap  of  8.5  million  adults  with  co-occurring 
addiction  and  mental  health  disorders.* 30  In 
2010,  only  37.6  percent  of  facilities 
nationwide  that  provided  addiction  treatment 
services  offered  services  specific  to  patients 
with  co-occurring  addiction  and  mental 
health  disorders.31 

•  In  20 1 0,  adults  with  a  mental  illness  were 
more  than  1.5  times  as  likely  as  those 
without  a  mental  illness  to  have  smoked 
cigarettes  in  the  past  year  (41.3  percent  vs. 


Comparable  data  on  those  with  mental  health 
disorders  are  not  available  for  those  ages  12-17. 
1  And/or  a  reported  major  depressive  episode. 
*  Research  indicates  that  young  people  with  co- 
occurring  conditions  are  more  easily  identified  as 
needing  treatment  than  those  with  addiction  only. 
One  study  found  that  unmet  treatment  need  (i.e.,  the 
treatment  gap)  was  greatest  for  teens  with  addiction 
(37  percent)  compared  to  a  relatively  lower  treatment 
gap  of  23  percent  among  those  with  a  psychiatric 
disorder  only  and  19  percent  among  those  with  co- 
occurring  disorders.  Other  research  confirms  that 
rates  of  addiction  treatment  are  approximately  three 
times  higher  for  adolescent  illicit  drug  users  who 
report  having  received  mental  health  treatment  in  the 
past  12  months  compared  to  those  who  have  not 
received  mental  health  treatment. 


25. 1  percent).    Even  though  patients  with 
mental  health  disorders  are  likelier  to 
smoke33  and  about  as  likely  to  want  to  quit 
smoking  as  smokers  in  the  general 
population,34  research  suggests  that  smoking 
cessation  services  for  these  patients  are 

§  35 

rare. 

•  In  2010,  nearly  half  (46.8  percent)  of 
individuals  who  were  arrested  or  booked  in 
the  past  year,  but  not  incarcerated  at  the  time 
of  the  survey,  were  in  need  of  addiction 
treatment  (relative  to  8.0  percent  of  those 
who  had  not  been  arrested  or  booked  in  the 
past  year);  27.9  percent  of  those  in  need  of 
treatment  received  it,  leaving  a  treatment 
gap  of  2.5  million  individuals."  36  In  2010, 
only  26.8  percent  of  facilities  nationwide 
that  provided  addiction  treatment  services11 
offered  services  specific  to  patients  involved 
in  the  criminal  justice  system.37  Among 
inmates,  only  1 1.2  percent  receive 
treatment. 

•  Individuals  involved  in  the  justice  system 
also  are  likelier  than  the  general  population 
to  smoke39  but  are  less  likely  to  receive 
tobacco  cessation  services.40  One  survey  of 
500  correctional  facilities**-- including  jails, 
prisons  and  juvenile  facilities— found  that  80 
percent  reported  that  their  facilities  had  no 
tobacco  cessation  programs  at  all.41 

•  In  2005,  of  veterans  from  the  military 
operations  in  Iraq  and  Afghanistan  who 
sought  health  care  from  the  Department  of 
Veterans  Affairs  (VA),  40  percent  screened 
positive  for  risky  alcohol  use  and  22  percent 


§  Based  on  research  documenting  health  care 
practice;  national  data  on  the  use  of  smoking 
cessation  treatments  in  this  population  are  not 
available. 

"  Comparable  treatment  admission  data  from  the 
Treatment  Episode  Data  Set  (TEDS),  described  on 
page  141  and  in  Appendix  A,  are  not  available  for 
this  population. 

n  Excluding  facilities  such  as  jails,  prisons  or  other 
organizations  that  treat  incarcerated  individuals 
exclusively. 

tJ  Accredited  by  the  National  Commission 
on  Correctional  Health  Care. 


-136- 


screened  positive  for  a  possible  addiction 
involving  alcohol*  However,  of  those  who 
screened  positive  for  risky  alcohol  use,  only 
3 1  percent  were  advised  in  the  past  year  to 
drink  less  or  stop  drinking;  4 1  percent  of 
those  with  a  possible  addiction  involving 
alcohol  were  given  such  advice.42  Another 
study  found  that  1 1.8  percent  of  soldiers 
who  returned  from  Iraq  reported  risky 
alcohol  use  but  only  0.2  percent  were 
referred  to  treatment  and  only  21.6  percent 
of  those  who  were  referred  were  seen  within 
90  days.43  And  although  the  Handbook  on 
Uniform  Mental  Health  Services  requires 
access  to  opioid  maintenance  therapy,  fewer 
than  one  in  five  veterans  diagnosed  with 
addiction  involving  opioids  receive  this  kind 
of  therapy  on  an  ongoing  basis.44 

Regional  Variations  in  the  Treatment  Gap 

Current  national  data  on  regional  differences  in 
the  proportion  of  individuals  in  need  of 
addiction  treatment  are  not  available. '  However, 
other  research  indicates  that  the  disparity 
between  the  number  of  people  who  need 
addiction  treatment  and  the  number  who  receive 
it  varies  substantially  among  states  and  regions 
of  the  country,45  with  southern  and  southwestern 
states  having  the  largest  estimated  treatment 
gaps  in  the  nation  and  the  northeast  having  the 
smallest  estimated  treatment  gap.46 

Although  reasons  for  these  geographical 
differences  in  the  treatment  gap  are  not  well 
understood,47  possible  explanations  include 
variations  among  states  in  funding  of  treatment 
services,  including  differences  in  coverage  of  the 
costs  of  these  services  in  state  managed  care 
systems.48  One  study  found  that  only  21  percent 
of  the  variation  among  states  in  the  percent  who 
receive  treatment  was  associated  with  variations 


Based  on  scores  on  a  version  of  the  AUDIT 
instrument  (see  Appendix  H).  Risky  drinking  was 
defined  as  an  AUDIT-C  score  of  four  or  higher  for 
men  and  three  or  higher  for  women.  Addiction  was 
defined  as  an  AUDIT-C  score  of  four  or  higher  for 
women  and  six  or  higher  for  men. 
'  Public  access  NSDUH  files  have  not  contained 
geographic  variables  since  1998. 


in  the  prevalence  of  addiction;  the  rest  of  the 
variation  is  attributable  to  these  other  factors.49 

Sources  of  Funding  for  Addiction 
Treatment 

Spending  on  addiction  treatment  totaled  an 
estimated  $28.0  billion  in  2010.  Whereas 
private  payers  (including  private  insurers  and 
self-payers)  are  responsible  for  55.6  percent 
($  1 .4  trillion)  of  medical  expenditures  in  the 
U.S.,  they  are  responsible  for  only  20.8  percent 
($5.8  billion)  of  addiction  treatment  spending.50 

Public  payers  picked  up  the  tab  for  79.2  percent 
($22.2  billion)  of  expenses  for  addiction 
treatment,  with  state  and  local  governments 
paying  for  44.8  percent  ($12.6  billion)  and  the 
federal  government  paying  for  34.4  percent 
($9.6  billion).51  (Figures  7.C) 

The  concentration  of  spending  for  addiction 
treatment  in  public  programs  suggests  that 
insurance  across  the  board  does  not  adequately 
cover  costs  of  intervention  and  treatment,  with 
costly  health  and  social  consequences  falling  to 
government  programs.  National  data*  indicate 
that  those  with  private  insurance  are  three  to  six 
times  less  likely  than  those  with  public  insurance 
to  receive  specialty  addiction  treatment.5  52 


1  From  a  study  examining  data  from  the  2002-2007 
editions  of  the  NSDUH.  It  is  not  possible  to 
determine  from  these  data  why  treatment  access 
differed  based  on  insurance  type  since  the  study 
could  not  take  into  account  important  factors  such  as 
individual  characteristics  and  circumstances  that  may 
relate  both  to  type  of  insurance  and  likelihood  of 
treatment  access  (e.g.,  symptom  severity,  SES). 
§  Defined  in  the  study  as  treatment  received  in 
hospital  inpatient  units,  outpatient  and  residential 
addiction  treatment  facilities,  mental  health  facilities 
and  methadone  maintenance  facilities.  Services 
provided  by  private  physicians  (including 
psychiatrists),  independent  practice  mental  health 
practitioners,  clergy,  in  prisons/jails  and  by  self-help 
groups  are  not  included  in  the  definition  of  treatment. 
Those  with  no  insurance  are  almost  twice  as  likely  as 
those  with  private  insurance  to  receive  specialty 
treatment. 


-137- 


Figure  7.C 

Public  vs  Private  Spending 


Medical  Care 


Addiction  Treatment 


Public 
44.4% 
($1.1  T). 


Private 
55.6% 
($1.4T) 


Public 
79.2% 
($22.2  B) 


Private 
20.8% 
($5.8  B) 


Source:  CASA  Columbia  (2012)  analysis  of  the  National  Expenditures  for  Mental  Health  Services  & 
Substance  Abuse  Treatment  1986-2005  (Table  A.1)  SAMHSA  Spending  Estimates  Project,  2010;  CMS  Office 
of  the  Actuary,  National  Health  Statistics  Group  with  our  estimated  dollar  updates. 


Privately-Funded  Treatment 

In  2010,  20.8  percent  ($5.8  billion)  of  addiction 
treatment  expenditures  came  from  private 
sources.  Private  spending  includes: 

•  56.6  percent  ($3.3  billion)  from  private 
health  insurance; 

•  30.5  percent  ($1.8  billion)  from  self-pay  by 
patients;  and 

•  12.9  percent  ($0.8  billion)  from  other  private 
sources,  such  as  charitable  donations  and 
charity  care/fee  waivers.53  (Figure  7.D) 

Publicly-Funded  Treatment 

In  2010  79.2  percent  ($22.2  billion)  in  addiction 
treatment  expenditures  came  from  public 
sources.  Public  spending  includes: 

•  45.3  percent  ($10.1  billion)  from  state  and 
local  government  non-Medicaid  sources; 

•  26.3  percent  ($5.9  billion)  from  Medicaid; 


Figure  7.D 

Components  of  Private  Addiction 
Treatment  Spending  (Total  $5.8B) 


Other  Private. 

Sources 
12.9%  ($0.8B) 


Self-Pay 
30.5%($1.8B). 


Private  Health 

Insurance 
56.6%  ($3.3B) 


Source:  CASA  Columbia  analysis  of  the  National  Expenditures  for  Mental 
Health  Services  &  Substance  Abuse  Treatment  1986-2005.  (2012). 


19.9  percent  ($4.4  billion)  from  other 
federal  funds  such  as  block  grants  to  states; 
and 

8.5  percent  ($1.9  billion)  from  Medicare.* 54 
(Figure  7.E) 


Medicaid  and  Medicare  are  government  programs 
with  state  and  federal  contributions.  Therefore,  the 
estimates  reported  in  the  federal,  state  and  local 
categories  are  exclusive  of  the  estimates  of  public 
funds  spent  through  Medicare  and  Medicaid 
programs. 


-138- 


Figure  7.E 

Components  of  Public  Addiction 
Treatment  Spending  (Total  $22.2B) 


Medicare 
8.5%  ($1 .9B) 


Other  Federal 
19.9%  ($4.4B) 


Medicaid 
26.3%  ($5.9B) 


Other  State  & 
Local 
45.3% 
($10.1B) 


Source:  CASA  Columbia  analysis  of  the  National  Expenditures 
for  Mental  Health  Services  &  Substance  Abuse  Treatment  1986- 
2005.  (2012). 


Trends  in  Spending  on  Addiction 
Treatment 


Expenditures  by  Providers  and 
Types  of  Services 

Most  expenditures  for  addiction 
treatment  are  to  non-hospital  based 
providers  offering  outpatient  services. 

Providers.  Treatment  providers 
whose  primary  role  is  addiction 
treatment  account  for  61.7  percent 
($17.3  billion)  of  the  total  spending  on 
addiction  treatment  ($28.0  billion).57 
These  expenditures  include: 

•    43.4  percent  ($12.2  billion)  by 
specialty  addiction  treatment 
centers; 


•     12.8  percent  ($3.6  billion)  by  specialty  units 
in  general  hospitals;  and 


Between  1986  and  2010,  direct  spending  on 
addiction  treatment  increased  from  $9. 1  billion 
to  an  estimated  $28.0  billion.  In  constant 
dollars,  direct  spending  on  addiction  treatment 
nearly  doubled  during  this  period,  while  the 
portion  of  direct  addiction  treatment  paid  by 
private  sources  fell  from  39.8  percent  to  20.8 
percent  and  the  portion  paid  by  public  sources 
rose  from  60.2  percent  to  79.2  percent.  While 
there  also  was  a  shift  from  private  to  public 
payment  of  medical  care  expenditures  during 
this  period,  the  shift  was  far  less  pronounced; 
private  source  payment  of  medical  expenditures 
dropped  from  61.2  percent  in  1986  to  55.7 
percent  in  2005  while  public  source  payment 
rose  from  38.8  percent  to  44.3  percent.55 


/  was  not  able  to  get  help  until  I  got  myself  into 
the  criminal  justice  system  and  was  then  placed 
into  treatment  as  a  condition  of  parole.  I  tried 
many  times  to  get  help  for  my  addiction  but  due 
to  the  lack  of  insurance  and  money,  was 
denied.56 


•  5.5  percent  ($1.5  billion)  by  specialty 
hospitals.58 

The  remaining  expenditures  (38.3  percent,  $10.7 
billion)  are  accounted  for  by  facilities  and 
individuals  that  have  another  primary  mission 
but  also  provide  addiction-related  services, 
including: 

•  8.8  percent  ($2.5  billion)  by  specialty  mental 
health  centers; 

•  7.9  percent  ($2.2  billion)  by  health 
professionals  other  than  physicians  such  as 
counselors,  social  workers  and 
psychologists; 

•  6.8  percent  ($1.9  billion)  by  general  hospital 
non-specialty  units  such  as  detoxification, 
when  a  patient  with  addiction  is  admitted  via 
the  emergency  room; 


—Respondent  to  CASA  Columbia's 
Survey  of  Individuals  in 
Long-Term  Recovery 


Not  considered  to  be  addiction  treatment. 


-139- 


•  6.7  percent  ($1.9  billion)  in 
insurance  administration; 

•  6.3  percent  ($1.8  billion)  by 
physicians; 

•  1 .2  percent  ($0.4  billion)  by 
nursing  homes  and  home  health 
care  providers;  and 

•  0.6  percent  ($0.2  billion)  in  retail 
prescription  drugs.59  (Figure  7.F) 

Services.  Total  addiction  treatment 
spending  in  2010  ($28.0  billion) 
included: 

•  92.7  percent  ($25.9  billion)  for 
services,  including: 

>  48.3  percent  ($13.5  billion) 
for  outpatient  services  (non- 
hospital,  38.4  percent,  $10.8 
billion  and  hospital,  9.8 
percent,  $2.8  billion); 

>  27.9  percent  ($7.8  billion)  for 

residential  (non-hospital 
inpatient)  services;  and 

>  16.5  percent  ($4.6  billion)  for 
inpatient  hospital  services; 

•  6.7  percent  ($1.9  billion)  in 
insurance  administration  fees;  and 

•  0.6  percent  ($0.2  billion)  for  retail 
prescription  drugs.60  (Figure  7.G) 


Figure  7.F 

Addiction  Treatment  and 

Related  Services  Spending* 

Physicians 
6.3% 
($1.8B)_ 

Insurance 

rtUi  1 1 11  llbu  dllUl  1  

6.7% 

Nursing 
Homes/Home; 
Health  Care 
Providers 
\      1 .2% 
\f$0.4B) 

Retail 
;  Prescription 
Drugs 
0.6% 
($0.2B) 
/          Specialty  Mental 
/             Health  Centers 
/  8.8% 

($1.9B) 

^\  ($2.5B) 

General  Hospital 
Non-Specialty 
6.8% 

($1.9B) 

/            B  Specialty 

Other  Health  _ 
Professionals 
7.9% 
($2.2B) 

/  Addiction 
/                H  Centers 

($12.2B) 

Specialty  --' 

Hospitals 
5.5% 

($1.5B)    Specialty  Units  J 
in  General 

Hospitals 
12.8% 

($3.6B) 

*  The  combination  of  spending  by  provider  type  and  spending  related  to  other 
categories  such  as  retail  prescription  drugs  and  insurance  administration  is  a 
function  of  the  way  the  national  expenditure  data  are  presented  by  SAMHSA. 
Source:  CASA  Columbia  analysis  of  the  National  Expenditures  for  Mental  Health 
Services  &  Substance  Abuse  Treatment  1986-2005.  (2012). 

Figure  7.G 

Spending  by  Service  (Total  $28.0B) 

Insurance 

Arlminktmtinn   j. 

Retail 
Prescription 

Drugs 
0.6%  ($0.2B) 

6.7%  ($1 .9B)  s<T 

Inpatient              /  \ 
Hospital         yf  \ 
16.5%  ($4.6B)^^/  \ 

( 

N.  Outpatient 
\^48.3%  ($13.5B) 

Residential  \ 
27.9%  ($7.8B)_^^ 

U 

Source:  CASA  Columbia  analysis  of  the  National  Expenditures  for  Mental 
Health  Services  &  Substance  Abuse  Treatment  1986-2005.  (2012). 

-140- 


Treatment  Admissions 

There  are  no  national  data  on  individuals  who 
receive  addiction  treatment  in  the  U.S.;  the 
national  data  that  are  available  represent 
admissions  to  treatment  facilities  for  addiction 
involving  alcohol  or  other  drugs  (excluding 
nicotine)  for  the  79.2  percent  of  addiction 
treatment  funding  that  comes  from  public 
sources,  although  some  of  these  facilities  also 
may  receive  private  funding/ 


While  some  addiction  treatment  programs  may 
address  nicotine,  they  do  not  report  these  services  in 
their  treatment  admission  data. 
'  These  analyses  are  based  on  data  from  the 
Treatment  Episode  Data  Set  (TEDS),  a  national 
database  of  information  on  the  demographic  and 
addiction  characteristics  of  admissions  to  and 
discharges  from  addiction  treatment  facilities, 
routinely  collected  by  each  state  substance  abuse 
agency  and  submitted  to  the  Substance  Abuse  and 
Mental  Health  Services  Administration  (SAMHSA). 
TEDS  collects  information  about  the  beginning  and 
termination  of  treatment  episodes;  multiple  episodes 
of  treatment  for  the  same  client  are  counted 
separately.  The  2009  TEDS  data  are  based  on 
information  on  the  demographic  and  substance  use 
characteristics  of  the  approximately  1.5  million 
annual  admissions  to  alcohol  and  other  drug 
addiction  treatment  facilities  (excluding 
detoxification),  among  those  ages  12  and  older,  that 
report  to  individual  state  substance  abuse  agency  data 
systems.  The  TEDS  attempts  to  include  all 
admissions  to  providers  receiving  public  funding; 
however,  because  each  state  or  jurisdiction  decides 
the  TEDS  eligibility  of  a  provider,  there  is  no 
independent  check  on  the  actual  sources  of  funding. 
Although  SAMHSA  requests  submission  of  TEDS 
data  on  all  admissions  to  any  publicly  funded 
treatment  facility,  reporting  in  some  state  agencies  is 
structured  so  that  only  patients  treated  with  public 
funds  are  included  in  the  TEDS.  The  number  of 
patients  in  these  facilities  whose  treatment  is  not 
publicly  funded  is  unknown.  Because  the  scope  of 
facilities  included  in  the  TEDS  is  affected  by 
differences  in  state  licensure,  certification, 
accreditation  and  disbursement  of  public  funds,  the 
TEDS,  while  comprising  a  significant  proportion  of 
all  admissions  to  addiction  treatment,  does  not 
include  all  admissions.  (See  Appendix  A  for  more 
information  about  TEDS.)  It  is  important  to  note  that 
CAS  A  Columbia's  analyses  of  TEDS  data  exclude 
detoxification  services  in  calculating  rates  of 


P 
E 
R 
C 
E 
N 
T 


In  2009/  there  were  1.5  million  admissions  to 
publicly-funded  addiction  treatment  facilities.5 
More  than  half  (55.6  percent)  of  the  admissions 
were  for  addiction  involving  multiple 
substances.  For  38.6  percent  of  the  admissions, 
alcohol  was  the  primary  substance  of  addiction, 
compared  with  29.0  percent  for  illicit  drugs 
other  than  marijuana,  22.4  percent  for  marijuana 
and  7.9  percent  for  controlled  prescription 
drugs.61  (Figure  7.H) 


Figure  7.H 

Admissions  to  Publicly-Funded  Addiction 
Treatment  by  Primary  Substance 
and  Multiple  Substances 


55.6 

38.6 

29.0 

22.4 

i  

n 

7.9 
1  1 

Alcohol 


Marijuana 


Prescription 
Drugs 


Illicit  Drugs 
Other  Than 
Marijuana 

Note:  Admissions  for  addiction  involving  multiple  substances 
also  are  included  in  the  other  categories. 
Source:  CASA  Columbia  analysis  of  The  Treatment  Episode 
Data  Set  (TEDS),  2009. 


Multiple 
Substances 


Admissions  to  publicly-funded  addiction 
treatment  reflect  greater  attention  to  addiction 
involving  illicit  drugs  other  than  marijuana  and 
multiple  substances  relative  to  the  prevalence  of 
addiction  involving  these  substances  in  the 
population. 


62 


admissions  to  addiction  treatment;  therefore,  data 

reported  in  this  report  may  differ  from  those 

published  in  TEDS  reports. 

*  The  most  recent  available  data. 

§  Included  in  the  TEDS  database. 

Of  those  needing  addiction  treatment,  80.7  percent 
involve  alcohol,  18.9  percent  involve  marijuana,  10.3 
percent  involve  controlled  prescription  drugs  and  7.0 
percent  involve  illicit  drugs  other  than  marijuana; 
14.6  percent  involve  multiple  substances. 
(Categories  are  not  mutually  exclusive.) 


-141- 


Between  2002  and  2009,  treatment 
admissions  to  publicly-funded  addiction 
treatment  increased  by  7.0  percent  (from 
1.4  million  to  1.5  million).  During  that 
time,  admissions  where  prescription 
drugs  were  the  primary  substances  of 
addiction  increased  the  most— by  92.7 
percent;  admissions  where  marijuana  was 
the  primary  substance  of  addiction 
increased  by  13.1  percent.  At  the  same 
time,  admissions  where  illicit  drugs  other 
than  marijuana  were  the  primary 
substances  of  addiction  declined  by  1 1.0 
percent  and  admissions  where  alcohol 
was  the  primary  substance  of  addiction 
declined  by  6.5  percent.  Between  2002 
and  2009,  admissions  for  addiction 
involving  multiple  substances  declined 
by  1.2  percent.63  (Figure  7.1) 

Treatment  Referrals  and 
Venues 

CAS  A  Columbia's  NABAS  found  that 
46.8  percent  of  respondents  would  turn  to 
a  health  professional— such  as  their 
physician  (27.8  percent),  a  health 
professional  other  than  their  primary  care 
physician  (19.7  percent)  or  a  mental 
health  professional  (9.2  percent)  f~ if 
someone  close  to  them  needed  help  for 
addiction.64  (Figure  7. J) 


Figure  7.1 

Trends  in  Admissions  to  Publicly-Funded 
Addiction  Treatment  by  Substance,  2002-2009 


70.0 

60.0 

p 

50.0 

E 

R 

40.0 

C 

E 

30.0 

N 

20.0 

T 

10.0 

0.0 

•Multiple 
Substances 

•  Alcohol 


Illicit  Drugs  other 
than  Marijuana 

•  Marijuana 


2002      2004      2006      2008  2009 


Prescription 
Drugs 


Source:  CASA  Columbia  analysis  of  The  Treatment  Episode  Data 
Set  (TEDS),  2009. 


Figure  7.J 

Where  People  Would  Turn  for  Information/Help 
with  Addiction  for  Someone  Close  to  Them 

Primary  Care  Physician 

1  27.8 

Mutual  Support  Program 

1  ?1  0 

Other  Health  Professional 

I  19.7 

P 

"Do  Research/Look  It  Up" 

I  18.8 

E 

Addiction  Treatment  Center 

I  11.0 

R 

C 

Friend/Family  Member 

I       I  10.7 

E 
N 
T 

Church/Clergy  or  Relgious/Spiritual  Leader 

ZZI  9-8 

Mental  Health  Professional 

I  9.2 

Addiction  Hotline/Helpline 

I  7.2 

Source:  CASA  Columbia  National  Addiction  Belief  and  Attitude 
Survey  (NABAS),  2008. 

Not  including  mental  health  professionals. 
'  Some  respondents  chose  more  than  one  response  so 
the  46.8  percent  reflects  those  who  chose  either  one 
of  these  health  professionals. 


-142- 


Another  national  survey  found  that  65  percent  of 
adults  would  turn  to  a  health  care  provider  for  a 
problem  involving  alcohol.65  Despite  these 
findings,  the  smallest  proportion  of  referrals  to 
publicly-funded  addiction  treatment  comes  from 
health  professionals.66 

Of  all  the  admissions  to  publicly-funded 
addiction  treatment  in  2009,  44.3  percent  were 
referred  by  the  criminal  justice  system.  One- 
quarter  (25.3  percent)  of  referrals  came  from 
individuals,  including  concerned  family 
members,  friends  and  the  self-referred;f  12.1 
percent  were  referred  by  community  sources 
such  as  social  welfare  organizations,  religious 
organizations  and  mutual  support  programs;* 
10.6  percent  were  referred  by  addiction 
treatment  providers5*  for  additional  treatment  and 


Referrals  from  the  criminal  justice  system  include 
referrals  from  any  police  official,  judge,  prosecutor, 
probation  officer  or  other  person  affiliated  with  a 
federal,  state  or  county  judicial  system.  This 
category  also  includes  referrals  by  a  court  for 
DWI/DUI,  patients  referred  in  lieu  of  or  for  deferred 
prosecution,  during  pretrial  release,  before  or  after 
official  adjudication,  as  well  as  referrals  of  those  on 
pre -parole,  pre-release,  work  or  home  furlough  or 
Treatment  Alternatives  for  Safe  Communities 
(TASC). 

'  Separate  data  on  each  of  these  categories  are  not 
available  in  the  TEDS  dataset. 
*  Community  sources  of  referral  also  include 
government  agencies  that  provide  aid  in  the  areas  of 
poverty  relief,  unemployment,  shelter  or  social 
welfare  and  referrals  from  defense  attorneys. 
According  to  the  TEDS  data,  defense  attorneys  are 
not  included  in  the  criminal  justice  system  category; 
prosecutors  are  included  in  that  category.  These 
community  referral  categories  cannot  be  examined 
separately  in  the  TEDS  dataset. 
§  Addiction  service  providers  are  those  programs, 
clinics  or  health  care  providers  whose  principal 
objective  is  treating  patients  with  addiction,  or  where 
a  program's  services  are  related  to  substance  use 
prevention  or  education.  TEDS  distinguishes 
between  transfers  within  a  single,  continuous 
treatment  episode  and  the  initiation  of  a  new 
treatment  episode  but,  because  TEDS  relies  on  state 
administrative  systems  that  appear  to  differ  greatly  in 
their  ability  to  distinguish  transfers  within  a 
continuous  treatment  episode  from  the  initiation  of  a 
new  treatment  episode,  some  transfers  may  be 
reported  by  TEDS  as  new  treatment  episodes. 


5.7  percent  were  referred  by  a  health  care 
provider.    Very  few  treatment  referrals  came 
from  schools  (1.4  percent)1'  or  from  employers 
or  Employee  Assistance  Programs  (0.6 
percent).67  (Figure  l.K^) 


Figure  7.K 

Sources  of  Referral  to  Publicly-Funded 
Addiction*  Treatment 

Criminal  Justice  System 

1  44.3 

Individuals 

1  25.3 

P 

E 

Community  Sources 

1  12.1 

R 
C 
E 

Addiction  Treatment  Providers 

I  10.6 

Health  Care  Providers 

■  5.7 

N 
T 

Schools 

]  1.4 

Employers 

0.6 

*  Excluding  nicotine. 

Source:  CASA  Columbia  analysis  of  The  Treatment  Episode 
Data  Set  (TEDS),  2009. 

Given  that  addiction  is  a  medical  disease 
requiring  the  intervention  of  trained  medical 
professionals  and  the  high  prevalence  of  this 
disease  in  the  general  population,55  the  fact  that 
only  5.7  percent  of  treatment  admissions  are 
referred  by  health  professionals  highlights  the 
extent  to  which  health  professionals  fail  to 
address  this  disease  in  their  practice.  The  fact 
that  the  largest  proportion  of  referrals  to 
addiction  treatment  comes  from  the  criminal 
justice  system  further  underscores  how 
extensively  we  neglect  to  address  addiction  until 
the  consequences  are  too  dire  to  ignore.68  The 


Referrals  to  treatment  programs  from  health  care 
providers  include  those  from  physicians  (including 
psychiatrists)  or  other  licensed  health  professionals, 
or  from  a  general  hospital,  psychiatric  hospital, 
mental  health  program  or  nursing  home. 
(t  Including  a  school  principal,  counselor,  teacher, 
student  assistance  program  (SAP),  the  school  system 
or  an  educational  agency. 
"  These  data  are  from  the  TEDS  dataset. 
Comparable  data  on  referral  to  treatment  for  nicotine 
addiction  (smoking  cessation)  are  not  available.  The 
data  reported  here  do  not  include  referrals  to 
detoxification  programs. 
§§  See  Chapters  II  and  III. 


-143- 


separation  of  addiction  treatment  from 
mainstream  health  care  is  demonstrated  further 
by  the  fact  that  most  treatment  venues  are  not 
licensed  health  care  institutions.69 
(See  Chapter  IX.) 

Available  data  on  treatment  venues  to  which 
referrals  are  made  distinguish  between  intensive 
and  non-intensive  services  provided  in  non- 
residential settings  and  between  short-  and 
longer-term  services  provided  in  residential 

70 

settings: 

•  Non-residential  services  include  individual, 
family,  group  and/or  pharmaceutical 
therapies  provided  on  an  ambulatory  or 
outpatient  basis.  Intensive  services  are  those 
that  last  at  least  two  or  more  hours  per  day 
for  three  or  more  days  per  week. 

•  Residential  services  include  addiction 
treatment  provided  in  a  non-hospital  setting, 
and  24-hour  per  day  medical  care  in  a 
hospital  facility  that  includes  addiction 
treatment.  Short-term  services  include  those 
that  last  for  30  days  or  less  and  longer-terms 
services  are  those  that  last  for  more  than  30 
days. 

There  are  no  data  available  to  match  the  need  for 
specific  services  with  referrals  to  specific 
treatment  venues.  Although  referrals  to 
treatment  primarily  come  when  addiction  has 
advanced  to  the  point  of  serious  social 
consequences  (e.g.,  the  criminal  justice  system) 
and  often  involve  co-occurring  health 
conditions,  in  2009,  the  majority  of  the  1.5 
million  treatment  admissions  were  to  non- 
intensive  and  non-residential  venues:71 

•  63.3  percent  were  for  non-intensive,  non- 
residential services; 

•  14.6  percent  were  for  intensive,  non- 
residential services; 


•  11.9  percent  were  for  short-term  residential 
services;  and 

•  10.2  percent  were  for  longer-term  residential 
services.72  (Figure  7.L) 


Figure  7.L 

Admissions  to  Different  Types  of 
Treatment  Service  Venues 


p 

E 
R 

63.3 

C 

E 
N 

14.6 

11.9 

10.2 

T 

I I 

Non- 

Intensive  Non- 

Short-Term 

Longer-Term 

Intensive/Non-       Residential         Residential  Residential 
Residential  Services  Services  Services 

Services 

Source:  CASA  Columbia  analysis  of  The  Treatment  Episode 
Data  Set  (TEDS),  2009. 


While  most  admissions  regardless  of  referral 
source  are  to  non-residential  venues  (77.9 
percent),  certain  referral  sources  are  even  likelier 
than  average  to  result  in  admissions  to  non- 
residential services,  including: 

•  schools  (97.8  percent); 

•  the  criminal  justice  system  (85.5  percent); 

•  employers  (84.0  percent);  and 

•  community  sources  (79.3  percent).73 

In  contrast,  while  only  22.0  percent  of  treatment 
admissions  overall  are  referred  to  residential 
treatment  venues,  47.8  percent  of  those  referred 
by  addiction  treatment  providers  are  to 
residential  treatment  venues.74  (Table  7.1) 


-144- 


Table  7.1 

Admissions  to  Different  Types  of  Treatment  Service  Venues 
by  Source  of  Referral,  2009  (Percent) 


Source  oi 

Non- 

Intensive 

Snort- 1  erm 

Longer- 

Relerral 

Intensive 

Non- 

T»           "J           4.'  1 

Residential 

Term 

XT  

Non- 

Residential 

Residential 

Residential 

Total 

63.3 

14.6 

11.9 

10.2 

Criminal 

69.7 

15.8 

6.3 

8.1 

Justice 

System 

Individual 

61.0 

13.7 

14.2 

11.1 

Referrals 

Community 

62.3 

17.0 

11.2 

9.6 

Sources 

Addiction 

41.3 

10.9 

29.0 

18.8 

Treatment 

Providers 

Health  Care 

60.2 

12.7 

17.5 

9.6 

Providers 

Schools 

88.2 

9.6 

1.3 

0.9 

Employers 

67.3 

16.7 

13.6 

2.5 

Treatment  Completion 

In  2008,*  less  than  half  (42.1  percent)  of 
discharges  from  addiction  treatment  services1 
were  of  admissions  in  which  treatment  was 
completed.  * 75  The  highest  completion  rates 
were  from  venues  to  which  there  were  the  least 
referrals: 

•  14.8  percent  of  admissions  were  to  short- 
term  residential  services  which  had  the 
highest  completion  rate  of  54.8  percent; 

•  11.4  percent  of  admissions  were  to  longer- 
term  residential  treatment  which  had  a 
completion  rate  of  45.5  percent;  and 

•  73.8  percent  of  admissions  were  to  non- 
residential services  which  had  the  lowest 
completion  rate  of  39.1  percent.7 
(Figure  7.M) 


Source:  CASA  analysis  of  The  Treatment  Episode  Data  Set  (TEDS), 
2009. 


Figure  7.M 

Percent  of  Treatment  Admissions  and 
Completions  by  Different  Types  of 
Treatment  Service  Venues,  2008 


54.8 


I  Admissions 
1  Completions 


73.8 


14.8 


11.4 


45.5 


□ 


39.1 


Short-Term  Residential 
Services 


Longer-Term 
Residential  Services 


Non-Residential 
Services 


Source:  CASA  Columbia  analysis  of  The  Treatment  Episode 
Data  Set,  Discharges  (TEDS-D),  2008. 


Most  recent  available  data  on  discharges. 
'  Specifically,  those  that  received  state  funds  and 
reported  data  to  TEDS.  Data  include  only  those 
discharges  that  could  be  linked  to  admission  data  in 
the  2008  TEDS  dataset.  The  general  completion  rate 
among  all  discharges  (regardless  of  whether  they 
were  linked  to  admission  data)  was  42.1  percent. 
*  All  parts  of  the  treatment  plan  or  program  were 
completed. 


-145- 


Of  those  discharges  that  did  not  represent  a 
completed  treatment  episode,  46.6  percent 
dropped  out  of  treatment,  25.9  percent  were 
transferred  to  another  treatment  service  (whether 
or  not  the  patient  attended  that  program  is 
unknown),  12.8  percent  were  terminated  by  the 
program  and  4.5  percent  were  incarcerated.  The 
remainder  failed  to  complete  treatment  for  some 
other  reason.* 77 

Variations  in  Treatment  Completion  by 
Source  of  Referral 

Admissions  to  addiction  treatment  for  which  the 
source  of  referral  was  an  employer  were  the 
most  likely  to  complete  treatment  (57.2  percent 
of  admissions),  followed  by  referrals  from  the 
criminal  justice  system  (48.1  percent). 
Admissions  referred  by  health  care  providers 
and  individual  sources-including  concerned 
family  members,  friends  and  the  self-referred- 
were  the  least  likely  to  complete  treatment  (34.6 
percent  and  33.9  percent  of  admissions, 
respectively).78  Concern  about  potential  loss  of 
a  job  or  criminal  sanctions  might  help  account 
for  higher  rates  of  treatment  completion  among 
those  referred  by  employers  or  the  criminal 
justice  system.  (Table  7.2) 

Table  7.2 

Treatment  Completion  by  Source  of  Referral 


Source  of  Referral 

Percent 

Total 

42.1 

Employers 

57.2 

Criminal  Justice  System 

48.1 

Addiction  Treatment  Providers 

44.5 

Schools 

41.1 

Community  Sources 

36.6 

Health  Care  Providers 

34.6 

Individual  Referrals 

33.9 

Source:  The  Treatment  Episode  Data  Set  (TEDS) 
discharge  data,  2008.  


Variations  in  Treatment  Completion  by 
Primary  Substance  Involved 

Patients  admitted  to  treatment  with  addiction 
involving  alcohol  as  the  primary  substance  had 
the  highest  rate  of  treatment  completion  (50.7 
percent)  compared  with  39.3  percent  involving 
marijuana,  35.4  percent  involving  other  illicit 
drugs  and  35.3  percent  involving  prescription 
drugs.  The  treatment  completion  rate  for 
admissions  involving  multiple  substances  was 
38.9  percent 


79 


Variations  in  Treatment  Completion  by  Key 
Patient  Characteristics 

Male  patients  admitted  to  treatment  were  likelier 
than  females  to  complete  treatment  (48.5  percent 
vs.  42.6  percent  of  admissions).  No  significant 
age-related  differences  in  treatment  completion 
were  found.80  With  regard  to  racial/ethnic 
differences  in  treatment  completion,  Hispanics 
admitted  to  treatment  were  more  likely  to 
complete  treatment  than  were  whites  or  blacks 
(46.8  percent  vs.  37.9  percent  and  35.4  percent 
of  admissions,  respectively).'  81 

Link  between  Funding  Source, 
Type  of  Service  Provided  and 
Treatment  Completion 

Individuals  who  are  privately  insured  are 
substantially  less  likely  to  enter  addiction 
treatment  than  those  with  public  insurance.* 82 
Publicly-funded  admissions  to  addiction 
treatment  are  likelier  than  privately-funded 
admissions  to  be  for  more  intensive  services: 


i.e.,  moving,  illness  or  hospitalization,  death,  other 
reason  out  of  patient's  control  or  the  reason  for 
discharge  is  unknown  or  not  recorded. 


'  Similarly,  a  study  of  patients  receiving  treatment  for 
addiction  involving  alcohol  found  that  black  patients 
were  less  likely  than  white  or  Hispanic  patients  to 
complete  their  treatment  program,  regardless  of 
whether  they  were  enrolled  in  non-residential 
treatment  (17.5  percent  vs.  26.7  percent  and  29.7 
percent,  respectively)  or  residential  treatment  (30.7 
percent  vs.  46.1  percent  and  42.9  percent, 
respectively). 

*  Controlling  for  type  of  substance,  severity  of  the 
addiction,  demographic  characteristics,  current  health 
status  and  whether  the  individual  is  a  daily  cigarette 
smoker. 


-146- 


•  intensive  outpatient  (25.9  percent  vs.  15.1 
percent), 

•  short-term  residential  (21.6  percent  vs.  14. 1 
percent),  and 

•  longer-term  residential  (7.6  percent  vs.  3.0 
percent).83 

Privately- funded  admissions  are  likelier  than 
publicly-funded  admissions  to  be  to  non- 
intensive  outpatient  services  (67.6  percent  vs. 
44.7  percent),  have  a  higher  rate  of  treatment 
completion  (53.7  percent  vs.  42.9  percent)  and 
have  a  lower  rate  of  transfer  to  another  facility 
(12.2  percent  vs.  17.9  percent).84 

Existing  data  do  not  provide  an  explanation  for 
these  differences  and  no  data  are  available  on 
treatment  needs  and  outcomes  by  funding  source 
and  type  of  service  provided.  Possible 
contributing  factors,  however,  might  include  that 
privately-funded  admissions  are  likelier  to 
involve  less  severe  cases  of  addiction,  those  with 
private  resources  may  have  greater  access  to 
effective  support  services  or  quality  care,  or 
those  with  private  insurance  may  be  less  likely 
to  seek  treatment  perhaps  due  to  the  perceived 
stigma. 

Barriers  Patients  Face  in  Accessing 
and  Completing  Addiction 
Treatment 

In  addition  to  the  limited  private  sector  coverage 
of  addiction  treatment  and  the  lack  of  treatment 
referrals  from  the  health  care  system,  many 
other  barriers  stand  in  the  way  of  individuals 
accessing  and  completing  addiction  treatment. 
These  include:  a  misunderstanding  of  the 
disease,  negative  public  attitudes  and  behavior 
toward  those  with  the  disease,  privacy  concerns, 
cost,  lack  of  information  on  how  to  get  help, 
limited  availability  of  services  including  a  lack 
of  physicians  trained  in  addiction  care, 
insufficient  social  support,  conflicting  time 
commitments,  negative  perceptions  of  the 
treatment  process  and  legal  barriers.  Other 
factors  having  to  do  with  treatment  quality  are 
discussed  in  Chapter  X.  Rarely  is  there  only  one 


obstacle  to  a  person  receiving  needed 
treatment.86 

Although  comparable  national  data  for  barriers 
to  accessing  smoking  cessation  treatment  are  not 
available,  research  indicates  that  barriers  similar 
to  those  facing  individuals  seeking  addiction 
treatment  involving  alcohol  or  other  drugs  stand 
in  the  way  of  smokers  accessing  tobacco 
cessation  services.87 

Misunderstanding  of  the  Disease 

One  of  the  most  frequently  reported  barriers  to 
accessing  addiction  treatment  has  been  described 
as  patient  denial.88  However,  what  is  commonly 
viewed  as  denial  might  also  be  characterized  as 
a  misunderstanding  of  the  disease.  As  is  the 
case  for  seeking  treatment  for  other  health 
conditions  such  as  diabetes,  hypertension  or 
heart  disease,89  most  cases  of  denial  that  serve  as 
barriers  to  treatment  access  actually  involve 
cases  in  which  a  person  with  symptoms  of 
addiction  does  not  recognize  that  he  or  she  has  a 
treatable  disease,90  underestimates  the  severity 
of  the  disease91  or  does  not  believe  that  the 
symptoms  can  be  allayed  through  treatment.92 
Such  feelings  stem  not  only  from  a  lack  of 
public  awareness  about  the  true  nature  of 
addiction— that  it  is  a  brain  disease  that  can  be 
treated  effectively—but  from  the  disease  itself— 
one  effect  of  addictive  substances  on  the  brain  is 
that  judgment,  self-awareness  and  insight 
become  impaired.93  Continuing  to  misuse 
substances  despite  the  associated  harms  is  a 
defining  symptom  of  the  disease  of  addiction94 
and  in  many  cases  results  from  the  changes  that 
addictive  substances  produce  in  the  structure  and 
function  of  the  areas  of  the  brain  that  control 
judgment,  decision  making  and  behavioral 
inhibition  and  control.95 

In  one  survey  of  people  with  a  history  of 
addiction  in  their  families,  60  percent  cited 
denial  as  the  biggest  obstacle  to  getting  help  for 
addiction.96  The  majority  (71.7  percent)  of 
respondents  to  CASA  Columbia's  NAB  AS  think 
that  a  main  reason  why  people  with  addiction  do 
not  get  the  help  they  need  is  that  they  refuse  to 
admit  to  having  a  problem  or  that  they  do  not 


-147- 


want  to  quit.* 97  Another  study  found  that 
between  eight  and  1 6  percent  of  people  who  had 
been  assessed  but  had  not  entered  treatment 
cited  some  form  of  denial  as  the  barrier. f  98 

The  most  frequently-mentioned  barrier  to 
accessing  treatment  for  addiction  involving 
alcohol  and  drugs  other  than  nicotine  is  not 
being  ready  to  stop  using  these  substances.1 99  A 
study  of  current  smokers  in  Wisconsin  found 
that  the  main  barriers  to  quitting  that  participants 
reported  were  not  being  ready  to  stop  smoking 
because  they  enjoy  it  (79  percent),  would  crave 
it  (75  percent)  or  are  afraid  of  losing  the  stress 
relief  associated  with  it  (63  percent).100 

One  national  survey  found  that  among 
respondents  who  needed8  but  did  not  receive 
treatment,  only  3.3  percent  of  those  with 
addiction  involving  alcohol,  8.3  percent  of  those 
with  addiction  involving  another  drug 
(excluding  nicotine)  and  12.4  percent  of  those 
with  addiction  involving  multiple  substances 
(excluding  nicotine)  perceived  a  need  for 
treatment.101 

Treatment  providers  also  cite  denial  as  the  main 
barrier  to  treatment  access:  CAS  A  Columbia's 
survey  of  treatment  providers  in  New  York  State 
found  that  85.5  percent  of  program  directors  and 
84.9  percent  of  staff  providers  said  that  denial  of 
an  addiction  problem  "very  much"  stands  in  the 
way  of  people  looking  for  needed  addiction 

102 

treatment. 

Misunderstanding  of  the  disease  of  addiction 
also  is  reflected  in  public  policies  and  health 
care  practices  that  fail  to  integrate  treatment  for 


Respondents  were  asked  to  select  two  or  three 
reasons  from  a  list  read  to  them  by  the  interviewer. 
'  Eight  percent  of  respondents  believed  their  "drug 
use  is  not  causing  any  problems"  while  16.1  percent 
believed  they  "could  handle  their  drug  use  on  their 
own." 

*  As  reported  in  a  national  survey  of  individuals  ages 
12  and  older  who  recognized  they  needed  treatment, 
made  an  effort  to  get  treatment,  but  did  not  receive 
treatment.  These  estimates  are  from  combined 
national  data  from  2006-2009. 
§  Met  clinical  diagnostic  criteria  for  addiction 
involving  alcohol  or  drugs  other  than  nicotine. 


all  addictive  substances  including  nicotine  into 
standard  treatment  protocols.  (See  Chapter  X.) 

Negative  Public  Attitudes  and  Behaviors 
Toward  People  with  Addiction 

Related  to  widespread  misunderstanding  of  the 
disease  of  addiction  is  the  stigma  attached  to  it— 
the  well  documented,  strong  disapproval  of  or 
discrimination  against  those  with  the  disease— 
and  the  fear  of  repercussions  which  prevent 
people  with  addiction  from  getting  help.103 
Although  stigma  is  a  subjective  experience- 
perceived  disapproval  by  others  and  subsequent 
embarrassment  may  or  may  not  reflect  a  more 
objective  reality— there  is  a  long  history  of 
blaming  and  looking  down  on  people  with 
addiction104  rather  than  sympathizing  with  them 
as  we  do  for  those  with  other  health  conditions. 
The  fear  of  disapproval  or  rejection  can  derive 
from  an  individual's  own  low  self-esteem  or 
sense  of  shame  about  having  addiction  or  it  can 
derive  from  a  fear  of  abandonment  by  friends  or 
family  because  of  the  substance  use  itself,  the 
consequences  that  result  or  because  of  the 
decision  to  pursue  treatment.105 

Twenty-nine  percent  of  the  respondents  to 
CASA  Columbia's  NABAS  reported  that  the 
main  reason  why  people  with  substance-related 
problems  do  not  get  the  help  they  need  is  a  fear 
of  social  embarrassment  or  shame.106  Another 
national  survey  found  that  two-thirds  (67 
percent)  of  the  public  believe  that  a  stigma  exists 
toward  people  who  have  been  treated  for 
addiction  involving  alcohol  or  other  drugs."  107 
A  related  study  found  that  80  percent  of  the 
public  believes  that  there  is  a  stigma  against 
people  with  addiction  involving  alcohol  and  5 1 
percent  believe  this  stigma  is  maintained  even 
after  treatment  or  cessation  of  alcohol  use.108 

Smokers  also  face  a  stigma,  particularly  in  light 
of  increasing  anti-smoking  policies  and 
awareness  of  the  health  risks  of  smoking  and 
exposure  to  environmental  tobacco  smoke.109 


This  survey  excluded  addiction  involving  nicotine. 
Stigma  was  defined  for  respondents  as  "something 
that  detracts  from  the  character  or  reputation  of  a 
person;  a  mark  of  disgrace." 


-148- 


One  survey  of  New  York  City  residents  found 
that  39  percent  said  that  "Most  people  think  less 
of  a  person  who  smokes"  and  21  percent  said 
that  "Most  people  believe  smoking  is  a  sign  of 
personal  failure."110 

Over  40  percent  (4 1 .4)  of  respondents  to  the 
NABAS  reported  that  discrimination  against 
people  in  recovery  from  addiction  involving 
nicotine,  alcohol  or  prescription  or  illegal  drugs 
is  a  very  (15.8  percent)  or  somewhat  (25.6 
percent)  serious  problem  in  their  community; 
51.0  percent  of  those  who  had  their  own  history 
of  addiction  thought  it  was  a  very  (24.5  percent) 
or  somewhat  (26.5  percent)  serious  problem.111 

Thirty-eight  percent  of  the  respondents  to  the 
NABAS  reported  that  the  main  reason  why 
people  with  addiction  do  not  get  the  help  they 
need  is  a  fear  of  adverse  consequences  like 
losing  a  job,  getting  expelled  from  school  or 
losing  child  custody.  Treatment  providers  also 
see  this  as  a  barrier  to  treatment  access:  CASA 
Columbia's  survey  of  treatment  providers  in 
New  York  State  found  that  a  significant 
proportion  of  the  respondents  said  that  the  fear 
that  one  will  be  discriminated  against 
"somewhat"  (48.2  percent  of  program  directors 
and  5 1 .4  percent  of  staff  providers)  or  "very 
much"  (39.8  percent  of  program  directors  and 
30.4  percent  of  staff  providers)  stands  in  the  way 
of  people  looking  for  needed  addiction 
treatment,  as  does  fear  of  losing  one's  job  (96.3 
percent  of  directors  and  94.2  percent  of  staff 
providers  said  this  "somewhat"  or  "very  much" 
stands  in  the  way  of  people  looking  for  needed 
treatment).112 

Another  recent  study  found  that  while  there  are 
no  significant  differences  in  employment  rates 
between  people  with  a  history  of  addiction  and 
those  without,  those  with  a  history  of  addiction 
report  significantly  higher  rates  of  involuntary 
job  loss.  The  analyses  conducted  for  the  study, 
which  controlled  for  other  factors  that  predict 
employment  outcomes,  suggest  that  employer 
discrimination  may  be  an  important  contributing 
factor  to  job  instability  in  this  population.  The 
authors  speculate  that  while  the  Americans  with 


Defined  as  effectively  managing  their  disease. 


Disabilities  Act  of  1990  is  successful  in 
protecting  those  with  a  history  of  addiction  from 
experiencing  discrimination  in  the  hiring 
process,  it  might  be  less  successful  in  protecting 
those  people  from  job  termination.113 

Individuals  with  a  lifetime  diagnosis  of 
addiction  involving  alcohol  are  less  likely  to 
access  treatment  or  support  services f  if  they 
perceive  that  addiction  carries  a  stigma.114 

Respondents  to  the  NABAS  admit  that  they 
would  discriminate  against  people  who  have  a 
history  of  addiction,  being  less  likely  to  hire 
former  smokers  or  those  in  recovery  from 
addiction  involving  alcohol  or  other  drugs.115 

•  53.6  percent  of  respondents  said  that  they 
would  be  less  likely  to  hire  a  qualified 
applicant  upon  learning  that  he  or  she  is  in 
recovery  from  addiction  involving  illicit 
drugs; 

•  41.1  percent  would  be  less  likely  to  hire  a 
qualified  applicant  in  recovery  from 
addiction  involving  controlled  prescription 
drugs; 

•  27.9  percent  would  be  less  likely  to  hire  a 
qualified  applicant  in  recovery  from 
addiction  involving  alcohol;  and 

•  6.6  percent  would  be  less  likely  to  hire  a 
qualified  applicant  who  is  a  former 
smoker.116 

In  comparison,  18.0  percent  said  they  would  be 
less  likely  to  hire  a  qualified  applicant  who  had 
been  treated  for  depression,  about  nine  percent 
said  that  they  would  be  less  likely  to  hire  a 
qualified  applicant  who  had  been  treated  either 


1  Defined  in  this  study  as  including  services  delivered 
in  an  inpatient  ward,  outpatient  clinic,  rehabilitation 
program,  halfway  house,  emergency  room  or  crisis 
center  or  by  a  private  physician,  psychiatrist, 
psychologist,  social  worker  or  other  professional; 
alcohol  or  other  drug  detoxification;  and  self- 
help/mutual  support  programs  (e.g.  AA)  or  social 
services  (family  services  or  services  delivered  by  an 
employee  assistance  program  or  by  clergy). 


-149- 


for  obesity  or  heart  disease  and  about  five 
percent  said  the  same  for  diabetes,  asthma  or 


cancer/  117  (Figure  7.N) 


Figure  7.N 

Participants  Reporting  They  Would  Be  Less  Likely* 
to  Hire  a  Qualified  Candidate  in  Recovery 
from/Treated  for  Each  Condition: 


Addiction-Illicit  Drugs 
Addiction-Prescription  Drugs 
Addiction-Alcohol 
Depression 
Obesity 
Heart  Disease 
Smoking 
Diabetes 
Asthma 
Cancer 


53.6 


41.1 


■  27.9 


I  18.0 


9.4 

9.2 


I  6.6 

5.4 
4.8 
4.7 


*  Among  those  who  responded  "somewhat  less  or  much  less  likely1 
Source:  CASA  Columbia  National  Addiction  Belief  and  Attitude 
Survey  (NABAS),  2008. 


Another  study  found  that  43  percent  of  the 
public  would  be  less  likely  to  vote  for  a 
gubernatorial  candidate  who  was  in  recovery 
from  addiction  involving  alcohol  or  other  drugs 
(excluding  nicotine). 


Perhaps  because  of  the  lingering  view  that 
addiction  results  from  lack  of  will  power  or  self 
control  that  can  be  remedied  with  a  simple 
change  of  mind,  stigma  and 
discrimination  against  addicted 
individuals  are  all  too  common. 
Recent  research  finds  that  people 
with  addiction  are  seen  as  more 
blameworthy  and  dangerous 
compared  to  individuals  with  a 
"mental"  illness,  and  those  with 
a  "mental"  illness  are  viewed 
more  negatively  than  those  with 
a  "physical"  illness. 
Consequently,  those  with 
addiction  are  avoided  more  and 
helped  less.121  Research  also 
indicates  that  enhancing  the 
public's  understanding  of 
addiction  or  mental  health 
disorders  as  having  a 
neurobiological  basis  relates  to 
increased  public  support  for  providing  treatment 
services  to  individuals  with  these  conditions,  but 
has  not  yet  translated  into  less  of  a  stigma  or 
discrimination  associated  with  these 
conditions. 


P 
E 
R 
C 
E 
N 
T 


122 


118 


Discrimination  against  those  with  addiction  is 
manifested  on  the  governmental  and  institutional 
levels  as  well.  Insurance  companies  generally 
provide  less  coverage  for  addiction  treatment 
services  than  for  other  medical  services.119 
Although  the  passage  of  the  Paul  Wellstone  and 
Pete  Domenici  Mental  Health  Parity  and 
Addiction  Equity  Act  (MHPAEA)  of  2008,  and 
the  subsequent  2010  Patient  Protection  and 
Affordable  Care  Act,  were  significant 
breakthroughs,  the  laws  contain  exemptions  and 
loopholes  that  may  continue  to  limit  access  to 
addiction  treatment.1  120 


The  stigma  associated  with  addiction  is 
compounded  by  its  high  rate  of  co-occurrence  with 
mental  illness. 

'  For  example,  MHPAEA  does  not  require  health 
insurance  plans  to  offer  coverage  for  mental  health  or 
addiction  treatment  services,  employers  with  fewer 
than  50  employees  are  not  covered  by  the  law,  and  if 
the  projected  cost  increase  is  too  high  for  health 


Privacy  Concerns 

Because  of  negative  public  attitudes  toward 
addiction  and  the  consequent  potential  for 
stigma  and  discrimination,  prospective  patients 
for  addiction  treatment  may  have  concerns  about 
the  extent  to  which  their  identity  and  the  details 
of  their  treatment  will  stay  private  and 
confidential.123 

Prospective  patients  sometimes  believe  that 
providers  violate  patients'  confidentiality.124 

insurance  plans  (more  than  two  percent  in  the  first 
year  and  more  than  one  percent  in  subsequent  years), 
then  insurance  companies  may  request  an  exemption 
from  the  law.  Under  the  ACA,  mental  health  and 
addiction  treatment  services  must  be  offered  in 
individual  and  small  group  health  plans  as  part  of 
essential  health  benefits,  but  the  scope  of  these 
benefits  will  likely  vary  by  state.  See  Chapter  VIII 
for  a  more  complete  discussion  of  health  insurance 
coverage  for  addiction  prevention  and  treatment 
services. 


-150- 


Privacy  concerns  are  particularly  acute  in  rural 
populations  where  patients  may  fear  a  lack  of 
anonymity  due  to  relatively  smaller  and  more 
close-knit  communities.125 

Another  element  of  privacy  concerns  involves 
the  aversion  of  some  individuals  to  key  elements 
of  the  therapeutic  process— participating  in 
individual  or  group  therapy  where  patients 
discuss  personal  or  intimate  details  with 
therapists  or  with  other  patients.126  In  one  study 
of  individuals  with  addiction,  36.5  percent  of 
respondents  said  they  do  not  like  talking  in 
groups,  35.6  percent  said  they  do  not  like  to  talk 
about  their  personal  lives  with  other  people  and 
32. 1  percent  said  they  do  not  like  being  asked 
personal  questions.127  In  a  study  of  risky  alcohol 
users,  50  percent  cited  a  combination  of 
concerns  about  privacy,  labeling,  asking  for  help 
and  sharing  problems  as  a  reason  for  not  seeking 

1  28 

treatment. 
Cost* 

Cost  is  one  of  the  most  frequently-reported  and 
long-standing  barriers  to  receiving  addiction 
treatment.129  Approximately  50  million 
Americans,  or  16.3  percent  of  the  United  States 
population,  had  no  health  insurance  in  2010. 130 
Twenty-nine  million  insured  people  are 
underinsured'  131  perhaps  prompting  them  to 
postpone  needed  treatment.  People  who  are 
uninsured  and  underinsured  not  only  have  higher 
rates  of  chronic,  relapsing  addiction,132  but  also 
generally  receive  less  preventive  care,  are  at 
more  advanced  disease  stages  at  the  time  of 
diagnosis,  receive  less  treatment  for  health 
conditions  and  have  higher  mortality  rates  than 
those  with  comprehensive  coverage.133 

A  2009  national  survey  found  that  nearly  half 
(49  percent)  of  U.S.  adults  feel  that  they  would 
not  be  able  to  afford  treatment  for  addiction 
involving  alcohol  or  other  drugs1  if  they  or 


See  Chapter  VIII  for  a  more  complete  discussion  of 
cost-related  issues  in  addiction  treatment. 
'  Those  with  health  insurance,  but  with  very  high 
medical  expenses  relative  to  their  incomes. 
*  This  survey  did  not  address  addiction  involving 
nicotine. 


someone  in  their  family  needed  it.  This 
perception  was  true  across  income  levels:  67 
percent  of  adults  with  annual  incomes  under 
$50,000  said  they  would  not  be  able  to  afford 
treatment,  as  did  30  percent  of  those  with 
incomes  between  $75,000  and  $100,000  and  25 
percent  of  those  with  incomes  above  $100,000. 
In  addition  to  those  with  the  lowest  income 
level,  other  groups  most  concerned  about 
affording  addiction  treatment  include  those  with 
a  high  school  degree  or  less  (65  percent),  those 
living  outside  of  metropolitan  areas  (56  percent) 
and  adults  ages  18-34  (56  percent).  The  survey 
also  found  that  75  percent  believe  that  people 
with  addiction  may  not  get  treatment  because 
they  lack  insurance  coverage  or  cannot  afford 
it.134 

Cost  is  a  barrier  to  seeking  treatment  even  for 
people  with  adequate  health  insurance.135  Some 
addiction  treatment  programs  do  not  accept  any 
insurance  payments— private  or  public— for  their 
services,136  and  insurance  coverage  for  addiction 
treatment,  when  it  exists,  often  has  higher  co- 
pays  and  limited  service  coverage.137 


With  the  current  funding  stream,  you  must  be 
very  rich  or  very  poor  to  get  treatment. 138 

—Johnny  Allem 
Founder  and  President 
Aquila  Recovery,  Chartered 
Former  President  and  CEO 
Johnson  Institute 


People  with  private  insurance  tend  to  have 
greater  concerns  about  cost  and  are  likelier  to 
cite  cost  as  a  barrier  to  treating  addiction  than 
people  with  Medicaid  or  Medicare.  Those  with 
public  insurance  focus  more  on  accessibility 
issues  (waiting  times,  eligibility)  as  barriers  to 
treatment.139  This  disparity  may  be  due  to  the 
fact  that  some  private  insurance  companies  do 
not  cover  addiction  treatment  and  some 
employers  do  not  extend  their  benefit  plans  to 
include  addiction  treatment  coverage.140 

Twenty-eight  percent  of  respondents  to  the 
NABAS  think  that  one  of  the  main  reasons  why 
people  do  not  get  the  help  they  need  for 


-151- 


addiction  is  because  of  insufficient  available  and 
affordable  treatment  services.141  Treatment 
providers  see  this  as  a  barrier  to  treatment  access 
as  well:  CASA  Columbia's  survey  of  treatment 
providers  in  New  York  State  found  that 
approximately  90  percent  of  the  respondents 
said  that  inability  to  pay  "somewhat"  (44.6 
percent  of  program  directors  and  42.8  percent  of 
staff  providers)  or  "very  much"  (45.8  percent  of 
program  directors  and  50.7  percent  of  staff 
providers)  stands  in  the  way  of  people  receiving 
needed  addiction  treatment.142 

Cost  not  only  is  a  barrier  to  entering  treatment, 
but  to  staying  in  treatment  as  well.  One  study 
found  that  people  randomly  assigned  to  receive 
free  methadone  maintenance  therapy  stayed  in 
their  treatment  programs  longer  than  those 
randomly  assigned  to  fee-for-service  treatment, 
even  though  the  fee  was  only  $2.50  per  day.143 

Lack  of  Information  about  How  to  Get 
Help 

A  significant  barrier  to  obtaining  addiction 
treatment  is  the  lack  of  knowledge  about  where 
to  go  for  help  and  the  limited  ability  of 
physicians,  parents  and  other  family  members, 
teachers,  coaches,  employers,  clergy  and  law 
enforcement  to  identify  the  signs  of  addiction  in 
others  and  know  how  to  help  patients  access 
effective  treatment.144  The  NABAS  found  that  16 
percent  of  respondents  believe  that  a  main 
reason  why  people  with  addiction  do  not  get  the 
help  they  need  is  because  of  insufficient 
information  about  how  and  where  to  get  help.145 

Limited  Availability  of  Services 

A  significant  barrier  to  treatment  is  the  lack  of 
appropriate  and  accessible  treatment  services.146 
This  barrier  is  due  to  insufficient  training  of 
medical  professionals  and  treatment  options  and 
the  lack  of  treatment  options  tailored  to 
individual  needs;  excessively  restrictive 
eligibility  criteria  in  some  treatment  facilities; 
long  waiting  times  for  treatment  entry  and  a  lack 
of  trained  addiction  physician  specialists  and  a 
lack  of  inclusion  of  addiction  medicine  as  a 
recognized  field  of  practice  by  the  American 


Board  of  Medical  Specialties,  as  discussed  in 
Chapters  IX  and  X. 

Approximately  half  of  respondents  to  CASA 
Columbia's  NABAS  reported  that  insufficient 
treatment  programs  and  services  for  people  with 
addiction  is  a  somewhat  or  very  serious  problem 
in  their  communities.147  Another  national  poll 
found  that  nearly  half  (47  percent)  of  the 
respondents  said  that  treatment  services  are 
lacking  in  their  community;  only  one  quarter 
indicated  that  there  are  enough  affordable, 
accessible  quality  treatment  centers  and 
services.* 148  CASA  Columbia's  survey  of 
treatment  providers  in  New  York  State  found 
that  a  significant  proportion  of  the  respondents 
said  that  a  lack  of  conveniently  located  treatment 
programs  "somewhat"  (62.2  percent  of  program 
directors  and  56.8  percent  of  staff  providers)  or 
"very  much"  (17.1  percent  of  program  directors 
and  21.6  percent  of  staff  providers)  stands  in  the 
way  of  people  seeking  needed  addiction 
treatment.149 

Some  individuals  who  need  addiction  treatment 
face  eligibility  criteria  for  program  entry  that  are 
too  stringent-including  a  patient's  ability  to  pay 
and  a  required  agreement  to  comply  with  all 
rules  and  treatment  protocols  regardless  of 
individual  goals.150  In  contrast,  the  main 
criterion  for  treatment  access  in  mainstream 
medicine  is  the  principle  of  medical  necessity, 
determined  by  a  physician;151  patients  seeking 
medical  treatment  rarely  have  to  meet  a 
threshold  level  of  problem  severity  or  agree  to 
comply  in  advance  with  particular  rules,  unless 
those  rules  are  designed  to  protect  the  patient's 
health  and  safety  (e.g.,  refusing  to  give  a  patient 
a  certain  medication  that  is  contraindicated  for 
medical  reasons,  requiring  cessation  of  certain 
medications  or  behaviors  prior  to  a  surgical 
procedure). 


Those  reporting  the  greatest  concern  about  the 
limited  treatment  options  in  their  communities 
included  respondents  with  incomes  below  $50,000 
(52  percent),  blacks  (67  percent),  those  who  knew 
someone  with  addiction  (58  percent)  and  those  who 
did  not  have  health  insurance  (56  percent). 


-152- 


Patients  who  do  meet  eligibility  criteria  and  are 
ready  to  enter  treatment  often  face  a  long  wait 
for  services-according  to  some  estimates,  up  to 
70  days152-due  to  limited  treatment 
availability.153  This  barrier  can  undermine  an 
individual's  fragile  resolve  to  enter  treatment.154 
Long  waiting  times  may  bias  treatment  entry  in 
favor  of  those  most  likely  to  succeed  with 
treatment,155  as  a  longer  wait  time  to  enter  a 
program  is  associated  with  pretreatment 
attrition.156  One  study  found  that  the  longer 
patients  have  to  wait  between  clinical 
assessment  and  the  first  treatment  session,  the 
less  likely  they  are  to  complete  subsequent 
treatment  sessions.157  CASA  Columbia's  survey 
of  treatment  providers  in  New  York  State  found 
that  a  significant  proportion  of  the  respondents 
said  that  long  waiting  lists  "somewhat"  (40.2 
percent  of  program  directors  and  49.3  percent  of 
staff  providers)  or  "very  much"  (22.0  percent  of 
program  directors  and  21.0  percent  of  staff 
providers)  stand  in  the  way  of  people  accessing 
needed  addiction  treatment.158 

Insufficient  Social  Support 

A  lack  of  social  support  can  serve  as  a  barrier  to 
treatment  access.  Individuals  with  addiction 
may  be  discouraged  openly  by  family  or  friends 
from  entering  treatment  or  may  have  more  subtle 
fears  that  loved  ones  will  think  badly  of  them  or 
will  be  embarrassed  or  ashamed  if  they  enter 
treatment.159  Even  among  those  who  may 
otherwise  seek  treatment,  continued  substance 
use  in  an  addicted  individual's  family  or  social 
network  can  increase  the  risk  of  continued  use, 
reduce  the  likelihood  of  treatment  entry  and 
derail  treatment  efforts.160 

Conflicting  Time  Commitments 

Competing  responsibilities  and  time 
commitments  related  to  one's  family  and  career 
are  common  reasons  for  not  seeking 
treatment.161  One  study  found  that  the 
opportunity  cost  of  a  person's  time-including 
both  time  spent  traveling  to  non-residential 
treatment  programs  and  time  spent  in  treatment 
that  otherwise  would  be  spent  on  work  or  leisure 
activities-is  one  of  the  main  barriers  to  seeking 
treatment.162 


Negative  Perceptions  of  the  Treatment 
Process 

Among  those  with  addiction  who  accept  that 
they  need  to  treat  their  disease  are  those  who 
believe  they  can  manage  it  themselves,  without 
professional  assistance.163  Such  a  belief  may 
derive  from  a  misperception  of  what  symptoms 
and  what  level  of  symptom  severity  constitute 
the  disease  of  addiction  and  require  professional 
assistance,  or  it  may  derive  from  the  belief  that 
treatment  simply  is  not  effective  and  will  not 
help.164  Some  of  this  concern  may  be  warranted 
given  the  nature  of  the  services  offered. 
(See  Chapter  X.) 

Twenty  percent  of  respondents  to  the  NABAS 
think  that  a  main  reason  why  people  with 
substance-related  problems  do  not  get  the  help 
they  need  is  that  they  do  not  believe  that 
treatment  would  help. 165  Treatment  providers 
see  this  as  a  barrier  to  treatment  access  as  well: 
CASA  Columbia's  survey  of  treatment  providers 
in  New  York  State  found  that  a  significant 
proportion  of  the  respondents  said  that  the  belief 
that  treatment  does  not  work  "somewhat"  (63.9 
percent  of  program  directors  and  59.0  percent  of 
staff  providers)  or  "very  much"  (32.5  percent  of 
program  directors  and  31.7  percent  of  staff 
providers)  stands  in  the  way  of  people  looking 
for  needed  addiction  treatment.166 

Some  individuals  with  addiction  have  negative 
perceptions  or  a  fear  of  treatment  providers  and 
programs  that  may  keep  them  from  seeking  and 
accessing  treatment.167  These  perceptions  can 
be  based  on  an  individual's  prior  negative 
experience  in  treatment,  anticipation  that  the 
treatment  process  will  be  unpleasant, 
assumptions  about  the  limited  efficacy  of 
treatment  or  a  general  fear  of  what  might  happen 
in  treatment.168 

With  regard  to  smoking  cessation,  there  is  a 
prevalent  belief  among  smokers  that  certain 
interventions,  particularly  nicotine  replacement 
therapy  (NRT),  may  not  be  safe.169  One  study 
found  that  66.0  percent  of  current  and  former 
smokers  expressed  concerns  about  the  safety  of 
NRT;  those  expressing  concern  were  less  likely 


-153- 


to  use  NRT  in  a  cessation  attempt  (30  percent 
vs.  49  percent).170 

Legal  Barriers 

Unlike  other  chronic  health  conditions,  addiction 
involving  illicit  drugs,  by  definition,  marks  a 
person  as  having  engaged  in  illegal  activity. 
Treatment  providers  see  this  as  a  barrier  to 
treatment  access:  CASA  Columbia's  survey  of 
treatment  providers  in  New  York  State  found 
that  a  significant  proportion  of  the  respondents 
said  that  fear  of  being  sent  to  prison  or  jail 
"somewhat"  (41.0  percent  of  program  directors 
and  42.8  percent  of  staff  providers)  or  "very 
much"  (42.2  percent  of  program  directors  and 
37.0  percent  of  staff  providers)  stands  in  the  way 
of  people  looking  for  needed  addiction 
treatment.171 

Barriers  to  Treatment  Access  and 
Completion  in  Special  Populations 

The  barriers  to  treatment  outlined  above  apply  to 
most  individuals  with  addiction;  however, 
certain  populations  face  additional  barriers  that 
exacerbate  the  difficulty  of  accessing  needed 
treatment.* 

Individuals  with  Co-occurring  Conditions 

An  estimated  20  percent  of  the  U.S.  population 
has  a  disability  that  limits  their  functioning.1  172 


The  special  populations  discussed  in  this  section  do 
not  necessarily  mirror  those  discussed  in  Chapter  VI 
since  not  all  populations  that  require  specialized 
screening  or  treatment  protocols  have  barriers  to 
treatment  access  that  surpass  or  differ  from  those  of 
the  general  population  (e.g.,  individuals  involved  in 
the  justice  system).  Likewise,  not  all  special 
populations  that  have  additional  or  unique  barriers  to 
treatment  access  necessarily  require  specialized 
screening  or  treatment  protocols  (e.g.,  rural 
populations). 

*  Including  individuals  with  sensory  disabilities 
involving  sight  or  hearing;  physical  disabilities  that 
limit  basic  physical  activities  such  as  walking,  lifting, 
carrying;  mental  disabilities  that  involve  difficulty  in 
learning,  remembering  or  concentrating;  or 
disabilities  that  impede  self-care  such  as  dressing, 
bathing  or  getting  around. 


People  with  disabilities  use  addictive  substances 
at  nearly  twice  the  rate  of  the  general 
population.173  While  individuals  with  co- 
occurring  addiction  and  mental  health  disorders 
such  as  anxiety  and  depression  access  treatment 
at  higher  rates  than  individuals  in  the  general 
population  (although  most  treatment  facilities  do 
not  provide  services  tailored  to  this 
population),174  those  with  other  disabilities  that 
impede  functioning  access  treatment  services  at 
substantially  lower  rates  than  the  general 
population.175 

Many  health  and  social  service  professionals  fail 
to  identify  the  presence  of  risky  substance  use  or 
addiction  in  people  with  disabilities, 176  despite 
their  high  rate  of  substance  use.177  Many 
barriers  stand  in  the  way  of  treatment  for  people 
with  disabilities,  such  as  erroneous  attitudes  or 
beliefs  of  medical  providers,1  lack  of  staff 
training  in  how  to  work  with  disabled  people 
and  treatment  methods  and  materials  that  are  not 
tailored  to  the  needs  of  people  with 
disabilities.178  People  with  disabilities  who  have 
addiction  also  may  be  deterred  by 
accommodation  barriers  to  treatment,  such  as 
lack  of  personal  or  public  transportation  to  a 
treatment  center179  and  facilities  that  do  not  have 
adequate  accommodations,  such  as  restrooms, 
parking  facilities,  hallways  and  ramps  that  are 
accessible  to  patients  with  mobility 

1  80 

impairments. 

Treatment  personnel  often  do  not  have  the 
proper  training  to  meet  the  physical  and  other 
health  care  needs  of  patients  with  disabilities, 
such  as  knowledge  of  sign  language  or  Braille.181 
In  2009,  27.7  percent  of  facilities  offered 
services  in  sign  language  for  the  hearing 
impaired.182 


1  e.g.,  believing  that  people  with  disabilities  deserve 
pity  so  they  should  be  allowed  more  latitude  to 
engage  in  substance  use. 


-154- 


Pregnant  and  Parenting  Women 

Barriers  to  treatment  access  and  completion  can 
be  particularly  acute  for  women  who  are 
pregnant  or  post-partum,  despite  the  fact  that 
pregnancy  may  provide  substance-using  women 
with  the  motivation  they  need  to  reduce  their 
substance  use  or  seek  treatment.183  In  2010, 
only  15.9  percent  of  facilities  nationwide  that 
provided  addiction  treatment  services  offered 
services  specific  to  pregnant  or  post-partum 

184 

women. 

Limited  availability  of  child  care  for  parenting 
women  in  addiction  treatment  is  a  significant 
barrier  to  treatment  entry  and  retention. 
National  data  indicate  that  only  6.5  percent  of 
outpatient  addiction  treatment  facilities  that 
serve  women  offer  child  care,  although  facilities 
that  served  women  only  were  significantly 
likelier  than  facilities  serving  both  men  and 
women  to  offer  child  care  services.185 

Some  pregnant  smokers  report  reluctance  to  quit 
smoking  due  to  fear  of  weight  gain,186  not 
believing  in  the  harmful  effects  of  smoking  to 
themselves  or  their  fetus  due  to  prior 
pregnancies  with  no  observable  harm  and  a 
social  environment  where  smoking  is 
prevalent.187 

Some  women  also  fear  being  branded  as  "bad 
mothers"  by  treatment  personnel.188  One  study 
found  that  more  than  one-third  of  pregnant 
smokers  reported  being  apprehensive  about 
attending  smoking  cessation  counseling  because 
they  believed  the  counselor  would  judge  them 
harshly.189 

Pregnant  and  parenting  women  might  shy  away 
from  accessing  treatment  for  addiction  involving 
alcohol  or  other  drugs  (excluding  nicotine)  for 
fear  that  entering  treatment  may  result  in  losing 
custody  of  their  children;190  they  may  be 
apprehensive  of  the  involvement  of  child 
protective  services  if  they  were  to  be  identified 
as  having  addiction.191  CASA  Columbia's 
survey  of  treatment  providers  in  New  York  State 
found  that  a  significant  proportion  of  the 
respondents  said  that  fear  of  losing  child  custody 
"somewhat"  (25.3  percent  of  program  directors 


and  37.0  percent  of  staff  providers)  or  "very 
much"  (73.5  percent  of  program  directors  and 
58.7  percent  of  staff  providers)  stands  in  the  way 
of  people  looking  for  needed  addiction 

1  9? 

treatment. 

Substance  use  during  pregnancy  is  considered  a 
form  of  child  abuse  under  civil  child-welfare 
statutes  in  1 5  states  and  is  considered  grounds 
for  civil  commitment  (i.e.,  forced  admission  into 
a  treatment  program)  in  three  states.193  Pregnant 
substance  users  have  been  charged  with  such 
crimes  as  fetal  abuse,  child  abuse  and  neglect, 
delivering  drugs  to  a  minor,  corruption  of  a 
minor,  assault  with  a  deadly  weapon  and 
manslaughter.194  Some  states  have  used  prenatal 
substance  use  as  grounds  to  terminate  parental 
rights.195 

Adolescents 

Few  diseases  affecting  adolescents  are  as 
extensively  under-treated  as  addiction,  even 
though  addiction  is  a  disease  with  firm  roots  in 
adolescence.196  The  significant  treatment  gap  in 
the  adolescent  population- which  is  particularly 
acute  among  black  and  Hispanic  youth197-is  due 
in  large  part  to  the  failure  to  understand  the 
developmental  nature  of  addiction  and  the 
failure  of  health  care  professionals  to  look  for 
and  prevent  risky  substance  use  or  to  identify 
and  address  addiction  in  their  adolescent  patient 
populations.198 

The  Society  for  Adolescent  Health  and  Medicine 
has  called  for  greater  access  for  adolescents  and 
young  adults  to  health  care  through 
nontraditional  health  care  providers  such  as 
school  health  centers,  community  health  centers 
and  other  public  health  agencies  that  rely 
primarily  on  public  funding,  and  expanded 
insurance  coverage.199  Unfortunately,  systems 
responsible  for  the  welfare  of  young  people- 
schools,  juvenile  justice,  child  welfare—  too 
often  miss  opportunities  to  intervene  with  young 
people  in  need  of  treatment  and  continue  to 
allow  them  to  fall  through  the  cracks  undetected 
and  unaided.200 

Treatment  models  with  a  strong  evidence  base  in 
adult  populations  are  not  necessarily  applicable 


-155- 


to  the  treatment  needs  of  adolescents  with 
addiction.201  Yet,  effective  evidence-based 
treatment  approaches  for  adolescents  do  exist.202 
Despite  this,  in  2010,  only  28.8  percent  of 
facilities  nationwide  that  provided  addiction 
treatment  services  offered  adolescent-specific 

203 

services. 

Barriers  to  treatment  for  adolescents  include 
lack  of  support  among  parents  and  school 
personnel  and  lack  of  interest  on  the  part  of 
adolescents  in  participating  in  treatment.204 
These  barriers  may  result  in  difficulty  recruiting 
adolescents  to  participate  in  treatment.205  One 
national  survey  found  that  adolescents  frame 
their  reasons  for  not  wanting  to  participate  in 
treatment  as  they  "are  not  ready  to  stop 
substance  use,"  "didn't  want  others  to  find  out" 
and  because  they  "could  handle  the  problem 
without  treatment"— barriers  that  are  similar  to 
those  offered  by  the  general  population  and  are 
at  least  in  part  reflections  of  the  disease  itself 
and  of  the  stigma  attached  to  it.206  Other  barriers 
include  insufficient  research  on  the  safety  and 
efficacy  of  evidence-based  addiction  treatments 
for  use  in  adolescent  populations,  particularly 
pharmaceutical  therapies.207 

Older  Adults 

Older  adults  are  less  likely  than  younger  people 
to  be  identified  as  having  addiction  or  to  be 
referred  to  treatment;208  those  who  do  try  to 
access  treatment  often  have  difficulty  finding 
age-appropriate  treatment  services.209  In  2010, 
only  6.9  percent  of  facilities  nationwide  that 
provided  addiction  treatment  services  offered 
services  specific  to  older  adults.210 

Older  smokers,  for  example,  may  be  less  aware 
of  the  harmful  consequences  of  tobacco  use  and 
may  focus  more  on  the  perceived  benefits,  such 
as  its  use  as  an  aid  in  coping  with  stress  or 
controlling  weight.211  Some  may  feel  that  it  is 
"too  late"  to  reverse  the  effects  of  smoking  and 
therefore  may  not  be  motivated  to  seek  out 
smoking  cessation  services;  this  belief  is 
reflected  in  the  failure  of  many  health  care 
providers  to  counsel  older  adult  patients  to  stop 
smoking  and  support  them  through  a  cessation 
attempt.212  Some  physicians  may  have  concerns 


about  the  safety  of  prescribing  pharmaceutical 
interventions  for  smoking  cessation  to  older 
patients.213 

Adults  who  develop  late  onset  addiction 
involving  alcohol  are  less  likely  than  those  with 
early  onset  addiction  to  have  a  family  history  of 
addiction  (21  percent  vs.  72  percent)  and  are 
more  likely  to  try  to  hide  their  illness;  further, 
the  symptoms  associated  with  addiction 
involving  alcohol— such  as  disorientation  or 
confusion-may  be  misinterpreted  as  cognitive 
or  physical  deficits  such  as  dementia,  depression 
or  other  medical  problems  common  in  the 
elderly.214 

CASA  Columbia's  1998  report,  Under  the  Rug: 
Substance  Abuse  and  the  Mature  Woman,  found 
that  when  physicians  were  asked  for  five 
possible  diagnoses  of  a  hypothetical  68-year-old 
female  patient  with  an  array  of  complaints 
typical  of  risky  use  of  alcohol  or  prescription 
drugs,  only  one  percent  identified  a  substance 
use  problem  as  a  likely  diagnosis.  Contrary  to 
the  evidence,  only  62  percent  of  physicians 
reported  believing  that  addiction  treatment  is 
somewhat  or  very  effective  for  older  women.215 

The  Homeless 

Mental  illness  and  co-occurring  addiction  are 
highly  prevalent  in  the  chronically  homeless 
population.216  Addiction,  like  other  health 
problems  in  the  homeless  population,  too  often 
goes  unaddressed  until  it  is  severe  enough  to 
require  costly  urgent  care  and  hospitalization, 
resulting  in  a  great  deal  of  unnecessary  human 
suffering  and  a  serious,  yet  avoidable  burden  on 
health  care  systems.217 

Seeking  addiction  treatment  may  be  a  low 
priority  for  homeless  individuals  who  must 
contend  with  the  competing  needs  of  securing 
food,  clothing  and  shelter  and  who  rarely  have  a 
network  of  social  support  to  help  them  access 
and  succeed  in  treatment.218  Given  homeless 
individuals'  lack  of  resources,  their  ability  to 
find  appropriate  treatment  programs  and  pay  for 


In  a  study  of  men  ages  60  and  older  admitted  to  a 
VA  geriatric  outpatient  treatment  program. 


-156- 


services  can  be  extremely  limited.219  However, 
even  with  greater  motivation  and  better  access  to 
treatment,  the  environment  in  which  many 
homeless  people  spend  their  time—with  high 
rates  of  ambient  substance  use,  crime  and 
violence-may  present  additional  barriers  to 
seeking  and  receiving  treatment.220 

Lack  of  collaboration  between  social  service 
providers,  public  health  systems  and  addiction 
treatment  programs  is  another  significant 
obstacle  to  addressing  addiction  in  the  homeless 
population,  resulting  in  a  missed  opportunity  to 

22 1 

increase  access  to  treatment. 

Homeless  individuals,  who  frequently  have  co- 
occurring  addiction  and  mental  health  disorders, 
often  are  rejected  by  community-based 
residential  programs  since  housing  programs  for 
the  mentally  ill  frequently  exclude  substance 
users,  and  those  for  substance  users  often 
exclude  those  with  serious  mental  illnesses.222 
One  study  found  that  60  percent  of  homeless 
people  who  admitted  to  having  addiction 
reported  that  they  were  not  eligible  for  addiction 
treatment  or  subsidized  housing.  Forty-two 
percent  of  those  who  did  receive  treatment 
reported  that  their  treatment  was  ineffective 
because  of  a  lack  of  aftercare  and  housing 
services.223 

Another  study  found  that  receipt  of  public 
insurance  was  the  strongest  predictor  of  access 
to  treatment  among  homeless  people  relative  to 
other  predictors.  Jail  stays,  emergency 
department  visits  and  non-residential  medical 
care  visits  were  not  associated  with  increased 
access  to  treatment,  suggesting  that  referral  links 
between  these  services  and  addiction  treatment 
are  not  adequate.224 

Veterans  and  Active  Duty  Military 

According  to  the  U.S.  Department  of  Defense's 
Task  Force  on  Mental  Health,  service  members 
may  be  concerned  that  their  substance-related 
problems  might  impede  their  career 
advancement,  which  can  lead  them  to  avoid 
seeking  timely  care.225  Soldiers  may  be 
reluctant  to  seek  treatment  for  addiction  because 
self-referrals  can  be  reported  to  their  superiors; 


the  military  has  an  established  policy  of 
reporting  mental  health  and  substance-related 
problems  to  superiors.226  The  use  of  illicit  drugs 
or  the  misuse  of  controlled  prescription  drugs 
can  be  grounds  for  dishonorable  discharge.227 

Any  referral  for  additional  mental  health  care  in 
a  military  treatment  facility  must  be  documented 
in  an  individual's  personal  record  which  can 
deter  people  from  seeking  such  treatment.228 
Data  from  2007  show  that  since  military 
operations  began  in  Iraq,  army  commanders 
have  dismissed  more  than  twice  as  many 
soldiers  for  drug  use  than  they  did  in  the  same 
period  before  the  war.229  Drug  use  is 
categorized  as  a  form  of  "misconduct,"  which 
discontinues  some  or  all  military  benefits.230 

Another  barrier  to  accessing  treatment  for 
veterans  is  the  long  wait  time  for  initial 
appointments  or  between  appointments.231 
Veterans  with  co-occurring  health  problems  also 
face  barriers  to  treatment,  including  the  practice 
of  requiring  individuals  to  be  substance  free 
prior  to  entering  treatment  for  other  co-occurring 
conditions  that  are  common  among  military 
personnel,  such  as  post-traumatic  stress  disorder 
(PTSD).232 

More  generally,  there  is  a  significant  shortage  of 
medical  and  mental  health  professionals  to 
address  the  complex  medical  and  psychological 
treatment  needs  of  individuals  returning  from 
military  combat,  as  well  as  those  of  their  family 
members.233 

Rural  Populations 

Rural  populations  face  a  considerable  gap  in  the 
receipt  of  needed  addiction  treatment.234 
Limited  accessibility  to  treatment  services  as  a 
function  of  geographic  location  presents  a 
significant  obstacle  to  treatment  access  for 
people  living  in  rural  areas235  since  general 
medical  and  specialty  treatment  services 
typically  are  located  in  urban  centers.236  Only 
8.9  percent  of  all  addiction  treatment  facilities 
are  located  in  a  rural  county  that  is  not  adjacent 


The  use  of  illicit  drugs  or  the  misuse  of  controlled 
prescription  drugs. 


-157- 


to  an  urban  county.     In  2010,  8.9  million  rural 
residents  had  no  access  to  inter-city  public 
transportation,238  posing  a  significant  barrier  to 
treatment  access. 

Rural  residents  tend  to  have  lower  incomes  and 
are  less  likely  than  non-rural  residents  to  have 
health  insurance,  which  limits  their  ability  to 
afford  and  pay  for  treatment.239  And  since  rural 
residents  are  more  likely  than  urban  residents  to 
be  self-employed,  they  have  fewer  encounters 
with  employee  assistance  programs.240  For  these 
reasons,  rural  residents  who  engage  in  risky 
substance  use  or  have  other  health  problems  tend 
to  delay  seeking  preventive  care,  resulting  in  the 
need  for  more  costly  care  in  the  future.241 

Native  Americans 

National  data  on  racial/ethnic  differences  in  the 
addiction  treatment  gap  are  limited  with  regard 
to  Native  Americans  due  to  small  sample  sizes 
for  this  population.242  However,  existing  data 
suggest  that  Native  Americans  are  the  likeliest 
of  all  racial/ethnic  groups  to  smoke  and  to  meet 
clinical  criteria  for  addiction  involving  alcohol 
and  other  drugs.243  National  data  also  suggest 
that  the  group  with  the  largest  treatment  gap  is 
Native  Americans.244  One  estimate  indicates 
that  less  than  one-fifth  of  addiction  treatment 
programs  nationally  offer  specialty  services  for 
Native  Americans.245 


Chapter  VIII 
The  Spending  Gap 

Despite  the  evidence  that  risky  substance  use 
can  be  identified  and  reduced  through  screening 
and  early  intervention,  and  that  addiction  can  be 
treated  and  managed  effectively  with 
psychosocial  and  pharmaceutical  interventions, 
financial  investments  in  addressing  risky 
substance  use  and  addiction  are  aimed 
disproportionately  at  coping  with  the  costly 
health  and  social  consequences  of  the  disease 
rather  than  at  prevention  and  treatment.  This 
spending  gap  impairs  health  and  imposes 
extraordinary  and  unnecessary  costs  to 
taxpayers.  The  continued  inadequacy  of 
insurance  coverage  for  these  services  further 
flies  in  the  face  of  a  fiscally-sound  approach  to 
disease  prevention,  treatment  and  management. 

The  Rational  Approach  to  Risky 
Substance  Use  and  Addiction 

The  goals  of  medicine  are  the  prevention  of 
disease,  the  diagnosis  and  treatment  of  illness  or 
injury  and  the  relief  of  pain  and  suffering.1  The 
general  standard  for  determining  what  health 
care  services  should  be  provided  to  patients  is 
the  "reasonable  and  necessary"  2  or  the 
"medically  necessary"  standard.3  The  definition 
of  what  is  considered  necessary  generally  is 
made  by  health  care  payers  based  on  the  strength 
of  the  clinical  evidence  supporting  the 
effectiveness  of  interventions  in  improving 
health  outcomes.4  In  the  Medicare  and 
Medicaid  programs,  medical  necessity  is  defined 
in  various  ways  but  generally  as  the  prevention, 
diagnosis  or  treatment  of  illness  or  injury  that 
endangers  life,  causes  suffering  or  pain,  causes 
physical  deformity  or  malfunction  or  results  in 
illness  or  infirmity.5  Some  states  also  require 
that  Medicaid  services  not  be  more  costly  than 
reasonable  available  alternatives.6 


See  Chapters  IV  and  V. 


-159- 


The  American  Medical  Association  (AMA) 
supports  the  ideal  that  all  patients  have  "a  basic 
right  to  available,  adequate  health  care" 
regardless  of  the  ability  to  pay.7  This  ideal  is 
based  on  several  arguments  which  assert  a  moral 
obligation  to  treat  injuries  or  diseases  that 
impede  normal  functioning.* 8 

Addiction  is  not  unique  as  a  health  condition  for 
which  a  lack  of  understanding  of  the  nature  of 
the  disease  and  its  causes  has  resulted  in 
assigning  blame  to  the  patient  and  to  inadequate 
or  misguided  interventions;  other  historical 
examples  include  tuberculosis,  cancer, 
depression  and  HIV-AIDS.9  However,  once  a 
body  of  evidence  exists  about  the  nature  of  an 
illness  and  how  to  address  it,  that  information  is 
incorporated  into  medical  practice  and 
reimbursement  policies  based  on  the  obligation 
of  the  profession  to  treat  disease.  Addiction  is  a 
glaring  example  of  practice  lagging  behind  the 
science.10  The  science  is  unambiguous- 
addiction  is  a  complex  brain  disease  with 
significant  behavioral  characteristics11  that 
results  in  unhealthy  compulsive  behaviors,12 
diminished  cognitive  control,13  clinically- 
significant  impairment  or  distress14  and  that  can 
lead  to  long-term  disability  and  death.15  Our 
continued  failure  to  prevent  and  treat  the  disease 
is  inconsistent  with  ethical  standards  and  the 
goals  of  medical  practice. 


The  collective  social  protection  argument  posits  that 
certain  essential  services,  including  safety  and  health 
care,  are  a  "collective  responsibility"  of  society  and 
should  be  provided  to  all.  The  principle  of  fair 
equality  of  opportunity  calls  upon  institutions  to 
provide  individuals  with  basic  services  needed  to 
pursue  the  normal  range  of  opportunities  that  are 
essential  to  a  good  life— to  cultivate  one's  talents, 
develop  skills  and  formulate  one's  own  life  goals. 


Costs  of  Our  Failure  to  Prevent  and 
Treat  Addiction  as  a  Medical 
Condition 

Risky  substance  use  and  addiction  constitute  the 
leading  cause  of  death  and  disability  in  the 
United  States.16  The  result  of  not  providing 
effective  prevention  and  treatment  services  for 
addiction  is  that  the  cost  of  addiction  accrues, 
driving  many  other  diseases,  later  manifesting  as 
more  expensive  care  and  spilling  out  to  costly 
social  consequences. ' 

Looking  just  at  government  spending,  CASA 
Columbia  calculated  that  in  2005, 1  risky 
substance  use-  and  addiction-related  spending 
accounted  for  10.7  percent  of  federal,  state  and 
local  spending,  and  that  for  every  dollar  federal 
and  state  governments  spent,  95.6  cents  went  to 
pay  for  the  consequences  of  substance  use;  only 
1.9  cents  was  spent  on  any  type  of  prevention  or 
treatment.5  The  taxpayer  tab  for  government 
spending  on  the  consequences  of  risky  substance 
use  and  addiction  alone  totals  $467.7  billion  a 
year,  almost  $1,500  a  year  for  every  person  in 
America.17 

The  Largest  Share  of  Costs  Falls  to  the 
Health  Care  System 

The  largest  share  of  spending  on  the 
consequences  of  risky  substance  use  and 
addiction  is  in  health  care.18  Persons  with 
addictive  diseases  are  among  the  highest-cost 
health  care  users  in  America:19  they  have  higher 
utilization  rates,  more  frequent  hospital 
admissions,  longer  hospital  stays  and  require 
more  expensive  health  care  services.20  Nearly  a 
third  (32.3  percent)  of  all  hospital  inpatient  costs 
is  attributable  to  tobacco,  alcohol  and  other  drug 
use  and  addiction.21 

Even  family  members  of  individuals  with 
addiction  have  approximately  30  percent  greater 


f  See  Chapter  III. 

*  Most  recent  data  available. 

§  In  addition,  0.4  cents  was  spent  on  research,  1.4 

cents  on  taxation  or  regulation  and  0.7  cents  on 

interdiction. 


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health  care  costs  compared  to  families  with 
similar  demographic  characteristics  who  do  not 
have  a  member  with  an  addiction  diagnosis.22 

The  health  care  costs  associated  with  addiction 
also  stem  from  the  impact  that  addiction  has  on 
the  ability  to  treat  other  diseases.  Addiction 
affects  the  body  in  ways  that  complicate  health 
care,  for  example,  by  weakening  the  immune 
system.23  These  costs,  however,  rarely  are 
recognized.  One  study  found  that  from  1 994  to 
2002,  admissions  of  patients  with  addiction 
increased  46  percent  but  hospital  costs  increased 
134  percent;  because  only  one  percent  of  these 
patients  had  a  primary  diagnosis  of  addiction, 
the  rise  in  costs  was  attributed  to  treating  the  co- 
occurring  medical  illness  (i.e.,  the  primary 
diagnosis).24 

In  2010,  only  $28.0  billion  (1.0  percent)  of  total 
health  care  costs  was  spent  on  addiction 
treatment-related  services  involving  alcohol  or 
drugs  other  than  nicotine.  Approximately  $13.0 
billion  was  spent  on  treatment-related  services 
involving  alcohol  and  $15.0  billion  on 
treatment-related  services  involving  controlled 
prescription  or  illicit  drugs.'  25  Total  costs  of 
treatment  for  addiction  involving  nicotine  are 
unknown. 

In  2010,  the  U.S.  spent  $43.8  billion  to  treat 
diabetes26  which  affects  25.8  million  people,27 
$86.6  billion  to  treat  cancer28  which  affects  19.4 
million  people29  and  an  estimated  $107.0  billion 
to  treat  heart  conditions30  which  affect  27.0 
million  people,31  but  only  $28.0  billion  to  treat 
addiction1 32  which  affects  40.3  million 
people.5  33 


'Including  medical,  mental  health  and  direct 
treatment  costs. 

^  Treatment-related  services  include:  detoxification 
(which  is  not  considered  treatment)  and  diagnostic 
and  treatment  services  provided  in  inpatient  settings 
(usually  a  hospital),  outpatient/ambulatory  settings 
(such  as  in  a  hospital  outpatient  department  or 
emergency  department  and  in  physicians'  and  other 
medical  professionals'  offices  and  clinics)  and 
residential  settings  (24-hour  care). 
*  There  are  no  national  data  that  document  spending 
on  treatment  for  addiction  involving  nicotine; 
although  the  cost  estimate  of  $28.0  billion  applies  to 


Cost  Savings  of  Addiction 
Screening,  Intervention  and 
Treatment 

There  are  no  national  data  available  on  total 
health  care  spending  for  screening  or 
intervention  services;** 34  therefore,  data  on  cost 
savings  from  these  services  and  from  addiction 
treatment  come  from  individual  studies  rather 
than  national  data  sets. 

In  an  effort  to  increase  resources  directed  to 
screening,  intervention  and  treatment,  much 
attention  has  been  focused  on  highlighting  the 
cost  effectiveness  of  these  services.35  While  cost 
effectiveness  certainly  is  an  important 
component  of  resource  allocation  and  targeting, 
this  standard  as  applied  to  addiction  is  a  stark 
reminder  of  the  stigma  attached  to  the  disease.36 
The  United  States  does  not  use  cost 
effectiveness  as  a  measure  to  determine  which 
health  care  treatments  should  be  covered;  in  fact, 


the  treatment  of  addiction  involving  alcohol  and  other 
drugs  excluding  nicotine,  the  prevalence  estimate  of 
those  with  addiction  (40.3  million)  includes  those 
with  addiction  involving  nicotine. 
§  Due  to  data  limitations,  the  prevalence  estimates  for 
cancer  and  heart  conditions  include  individuals  ages 
18  and  older  who  have  ever  been  told  by  a  doctor  or 
other  health  professional  that  they  have  the  condition 
(cancer/malignancy  or  a  heart  condition).  The 
prevalence  estimate  for  diabetes  includes  all  ages  and 
the  estimate  for  addiction  includes  individuals  ages 
12  and  older;  for  diabetes  and  addiction,  the 
prevalence  estimates  include  both  diagnosed  and 
undiagnosed  cases.  In  each  case,  total  costs  of 
treatment  are  included  without  regard  to  age.  The 
cost  estimates  for  treating  diabetes,  cancer  and  heart 
conditions  were  inflated  to  2010  dollars  using  the 
medical  inflation  factor  (7.9  percent)  found  in  the 
Substance  Abuse  and  Mental  Health  Services 
Administration's  (SAMHSA)  National  Expenditures 
for  Mental  Health  Services  and  Substance  Abuse 
Treatment,  1 986-2005  publication. 

The  20 1 0  National  Drug  Control  Strategy  reports 
on  spending  in  one  grant  program  through  SAMHSA, 
which  spent  $29.1  million  in  grants  to  eight  states  to 
provide  screening,  brief  intervention  and  referral  to 
treatment  services  in  general  medical  settings,  and  to 
1 1  grant  recipients  to  include  training  in  these 
services  in  medical  residency  training  programs. 


-161- 


almost  no  other  disease  is  held  to  this  standard. 
However,  if  cost-effectiveness  were  an  essential 
factor  in  determining  which  medical  services  to 
fund,  then  screening,  interventions  and  treatment 
for  addiction  certainly  would  be  considered  a 
good  investment. 

One  study  found  that  the  annual  benefits  in 
avoided  health  care  spending  (i.e.,  cost-saving) 
per  person  achieved  through  substance-related 
interventions  in  200 1  dollars  ranged  from  $634 
for  brief  physician  interventions  for  risky 
drinkers  to  $3,951  for  standard  residential 
addiction  treatment;  the  average  annual  savings 
per  person  was  $1,939  across  all  interventions.38 

The  projected  cost  to  insurers  of  offering 
comprehensive  addiction  treatment  benefits  also 
is  modest.  According  to  a  1 999  study,  the  cost 
of  providing  managed,*  comprehensive* 
addiction  treatment  benefits  with  low  co- 
payments*  and  no  annual  limits  was  $5. 1 1  per 
member  in  1996- 1997. 39  Adding  managed, 
unlimited  addiction  treatment  benefits  to  a  plan 
that  previously  did  not  offer  addiction  treatment 
benefits  would  increase  costs5  only  by  an 
estimated  0.3  percent.**  40  In  2001,  the 
Congressional  Budget  Office  estimated  that 
mandating  parity  for  mental  health  and  addiction 
treatment  benefits  would  increase  group  health 
insurance  premiums  by  0.9  percent  initially  and 
by  0.4  percent  in  total  after  accounting  for  the 
market-driven  responses  of  health  plans, 
employers  and  workers  to  the  higher 
premiums.' '  41  Studies  of  the  effect  of  mandated 
parity  in  Federal  Employee  Health  Benefit  Plans 
have  concluded  that  total  plan  spending  per 


Benefits  carved  out  and  provided  by  a  large 
managed  behavioral  health  care  organization. 

*  Including  outpatient,  intensive  outpatient,  inpatient 
and  residential  treatment. 

*  $10  or  less. 

§  Costs  include  payments  to  providers;  administrative 
fees  and  profits  are  not  included. 

Assuming  annual  Health  Maintenance 
Organization  (HMO)  insurance  premiums  of  $1,500 
per  member. 

' r  Market-driven  responses  include:  reductions  in 
employers  offering  and  employees  enrolling  in 
employer-sponsored  insurance,  changes  in  the  types 
of  plan  offerings  and  reductions  in  scope  of  benefits. 


member  did  not  increase  significantly  while  out 
of  pocket  expenses  for  those  who  received 
treatment  benefits  declined.42 

Because  cost-effectiveness  research  to  date  has 
for  the  most  part  focused  on  the  cost  savings  of 
providing  a  particular  service  within  a  particular 
population,  it  is  not  yet  possible  to  generate  an 
overall  estimate  of  the  potential  cost  savings  of 
screening  all  patients  for  all  forms  of  risky 
substance  use  and  providing  appropriate 
interventions,  or  for  assessing  the  need  for 
treatment  and  providing  these  services. 
However,  as  the  following  examples  reveal,  the 
opportunity  for  cost  savings  is  substantial. 

Screening  and  Early  Intervention^ 

Cost-benefit  studies  of  screening  and  brief 
interventions  for  tobacco  and  alcohol  use  among 
adults  and  pregnant  women  have  demonstrated  a 
range  of  potential  costs  savings.43  Numerous 
studies  have  demonstrated  that  medical  costs  for 
patients  with  addiction  increase  significantly  as 
these  patients  age,44  implying  that  the  greatest 
cost  savings  can  be  achieved  by  early 
intervention  and  treatment. §§  45  In  the  health 
care  field,  treatment  costs  of  up  to  $50,000  for 
each  year  of  life  saved  are  considered  to  be  a 
worthwhile  investment  in  health  (i.e.,  cost 
effective);  in  specialty  care,  such  as  cancer, 
treatment  costs  of  up  to  $200,000  may  be 
considered  cost  effective.46 

Smoking.  Smoking  cessation  programs  yield 
positive  health  outcomes  at  the  low  cost  of 
$5,000  per  healthy  year  gained***  47  compared  to 
$56,200  per  year  for  Aspirin  and  statin  therapy 


11  Research  is  presented  related  to  screening  and 
interventions  for  smoking  and  risky  alcohol  use. 
Comparable  research  related  to  other  drug  use  is  not 
available. 

§§  Cost-benefit  studies  calculate  the  total  cost  savings 
that  result  from  providing  treatment  (sometimes 
called  return  on  investment);  whereas  cost- 
effectiveness  studies  determine  the  treatment  costs  of 
extending  a  patient's  life  by  one  year,  or  per  quality- 
adjusted  life  year  (QALY),  a  year  of  perfect  health. 

Cost  effectiveness  as  measured  by  costs  minus 
savings  for  each  year  of  healthy  life  attributable  to 
the  intervention. 


-162- 


to  prevent  coronary  heart  disease,  $191,635 
per  year  for  diet/exercise  to  prevent  diabetes  in 
high-risk  adults'  and  $30,619  per  year  for 
biennial  mammograms  to  screen  for  cancer 
among  women  ages  50  to  79.49 

Screening  pregnant  women  who  smoke  can  be 
especially  cost  effective,  given  that  the  smoking- 
attributable  medical  care  needed  by  infants 
whose  mothers  smoked  while  pregnant  is  an 
estimated  $367  million  per  year.1 50  A  one- 
percent  reduction  in  the  prevalence  of  smoking 
in  the  U.S.  population,  including  among 
pregnant  women,  would  reduce  the  number  of 
low-birth  weight  births  by  2,000,§  resulting  in 
$21  million  in  avoided  direct  medical  costs. 
Continuing  at  that  rate  for  another  six  years, 
more  than  57,000  low-birth  weight  births  could 
be  prevented,  saving  $572  million.51 

The  American  Legacy  Foundation  projected  that 
a  reduction  in  Medicaid  costs  of  nearly  one 
billion  dollars**  could  be  achieved  by  preventing 
the  current  cohort  of  24-year-oldstf  from 
smoking.  If  prevention  and  cessation  efforts 
were  successful  in  motivating  all  Medicaid 
recipients  who  smoke  to  quit,  states'  Medicaid 
expenditures  would  be,  on  average,  5.6  percent 
lower,  resulting  in  a  total  of  $9.7  billion  in 
savings  after  five  years.52 

Risky  Alcohol  Use.  Screening  and  brief 
intervention  for  risky  alcohol  use  rank  among 
the  top  most  cost-effective  prevention  services 
available,53  along  with  colorectal  cancer 


For  45-year  old  men  with  a  10-year  risk  for 
coronary  heart  disease  of  7.5  percent.  The 
calculation  includes  the  cost  of  medication  plus 
medical  care  including  care  for  adverse  events  (e.g., 
Aspirin-induced  gastrointestinal  bleeding  and 
resulting  morbidity  and  mortality). 
*  Costs  include  individually-tailored  diet  and  exercise 
plans,  visits  to  a  nutritionist  and  physical  training 
sessions. 
*In  1996  dollars. 
§  Based  on  1995  birth  rates. 
**  Over  the  cohort's  lifetime. 
' r  The  researchers  chose  this  age  because  nearly  all 
smokers  begin  smoking  before  age  24,  whereas 
younger  smokers  may  still  be  experimenting  with 
tobacco. 


screening,  hypertension  screening  and  influenza 
immunization.54 

Research  findings  suggest  that  early 
interventions8  for  risky  alcohol  use  may  result 
in  health  care  cost  savings  of  up  to  $43,000  for 
every  $10,000  invested.55  A  study  of  primary 
care  screening  and  brief  physician  intervention 
for  adult  risky  drinkers  yielded  a  net  benefit  of 
$947  per  person.56 

The  use  of  screening  and  brief  interventions  in 
hospitals  has  demonstrated  promising  returns  on 
investment.57  A  study  of  screening  and  brief 
interventions  for  risky  alcohol  use  among  adults 
in  trauma  centers  estimated  that  over  a  three- 
year  period,  the  cost  savings  associated  with 
screening  were  $89  per  patient55  and  the  cost 
savings  associated  with  brief  interventions 
lasting  30  minutes  were  $330  per  patient.  In 
total,  the  implementation  of  a  hospital-based 
alcohol  screening  and  brief  intervention  program 
for  risky  alcohol  use  was  estimated  to  reduce 
health  care  costs  by  $3.81  for  every  dollar 
spent.58  Brief  interventions" '  with  adolescents 
ages  1 8  and  1 9  who  were  admitted  to  a  trauma 
center  for  alcohol-related  injuries  also  have  been 
found  to  be  more  cost-effective  than  standard 

59 

care. 

The  return  on  investment  in  preventing  Fetal 
Alcohol  Syndrome  (FAS)  further  underscores 
the  importance  of  screening  and  early 
interventions.  The  added  medical  costs  for  a 
child  with  FAS  are  estimated  to  be  more  than 
$2,300  per  year  for  the  first  21  years  of  a  child's 
life.  An  alcohol  intervention  program  costing 
$50,000  that  could  successfully  prevent  at  least 
one  case  of  FAS  annually  would  pay  for  itself  in 
just  six  years.60 


11  Consisting  of  two  doctor  visits  and  two  nurse 

follow-up  calls. 

§§  Cost  per  screening  was  $16. 

Cost  per  intervention  was  $38.  Savings  were 
calculated  based  on  average  hospitalization  and 
emergency  department  costs;  hospital  recidivism 
rates  for  trauma  patients  with  and  without  addiction 
involving  alcohol;  and  the  efficacy  rate  of  screening, 
brief  interventions  and  referrals  to  treatment  at 
reducing  injury,  recidivism  and  hospital  readmission. 
' u  Using  motivational  interviewing. 


-163- 


Addiction  Treatment  and  Disease 
Management 

Persons  with  untreated  addiction  have  higher 
health  care  utilization  rates  and  more  frequent 
hospital  stays,  generating  billions  of  dollars 
in  largely  avoidable  health  care  charges.61 
Addiction  treatment,  particularly  evidence-based 
treatment,  not  only  reduces  health  care  costs  in 
both  the  short  and  long  term,  it  saves  lives  and 
reduces  other  social  consequences  and  costs  as 
well* 62  Some  research  suggests  that  treatment 
"pays  for  itself,"  often  on  the  day  it  is  delivered 
and  the  total  cost  savings  from  addiction 
treatment  continue  to  accrue  over  time.63 

While  the  total  economic  benefits  of  treatment 
are  greater  than  the  cost  of  treatment,64 
administrators  and  policymakers  too  often 
disregard  benefits  of  treatment  that  accrue 
beyond  the  narrow  silo  of  each  individual 
government  program.  For  example,  health  care 
payers  may  refuse  to  acknowledge  the 
significant  cost  savings  that  may  accrue  outside 
the  health  care  system  (increased  productivity, 
reduced  crime,  etc.).  An  example  of  this  can  be 
seen  in  an  analysis  of  data  from  the  VA  health 
care  system  from  1998  to  2006  showing  that 
providing  addiction  treatment  resulted  in  an 
overall  increase  in  health  care  costs,  presumably 
because  expanding  access  to  treatment  brought 
more  sick  patients  into  the  health  care  system 
and  more  of  their  co-occurring  medical 
conditions  subsequently  were  identified  and 
treated.  The  one  exception  was  opioid 
maintenance  therapy  which  paid  for  itself  in 
health  care  savings.  This  study  did  not  account 
for  potential  longer-term  reductions  in  health 
care  costs  or  for  potential  cost  savings  in  other 
sectors  because  it  was  taking  the  perspective  of 
an  insurance  payer— via  the  VA  health  care 
system65— and  this  perspective  tends  to  look  at 
short-term  costs  rather  than  long-term  savings. 

Most  studies— even  those  that  look  only  within  a 
particular  system  for  costs  and  benefits— find 
immediate  and  longer-term  savings  associated 
with  addiction  treatment: 


The  referenced  studies  do  not  include  detailed 
examples  of  the  nature  of  the  treatment  provided. 


•  A  longitudinal  study  of  patients  treated  for 
addiction  in  Kaiser  Permanente's  Medical 
Care  Program  found  an  average  reduction  of 
30  percent  in  medical  costs  three  years  post- 
treatment.  Significant  declines  were  seen  in 
areas  such  as  the  number  of  inpatient 
hospital  days  and  emergency  department 
visits,  which  are  high-cost  services.66 

•  A  comparison  of  adult  patients  who  met 
clinical  criteria  for  addiction  involving 
alcohol  or  drugs  other  than  nicotine  who 
were  enrolled  in  an  outpatient  treatment 
program  with  a  control  group '  found  that 
those  enrolled  in  the  treatment  program  were 
less  likely  to  be  hospitalized  1 8  months  after 
treatment  than  before  treatment.  The  study 
also  found  that  treatment  can  cut  health  care 
costs  associated  with  addiction  by  about  one 
quarter,  primarily  by  reducing  the  number  of 
annual  hospital  stays  and  the  likelihood  of 
emergency  room  visits.67 

•  An  analysis  of  data  from  patients  in 
treatment  for  addiction  involving  alcohol  or 
drugs  other  than  nicotine  in  California  found 
a  benefit-cost  ratio  of  more  than  seven  to 
one'}  the  average  cost  of  treatment  was 
$1,583  and  the  benefits§  were  $1 1,487. 
Most  of  the  savings  were  attributed  to 
reduced  crime  and  increased  employment.68 

•  An  analysis  of  statewide  data  from 
Washington  State  found  that  treatment  was 
associated  with  an  annual  $2,500  reduction 
in  medical  expenses**  among  adult  patients 


'  Adults  who  met  criteria  for  addiction  involving 
alcohol  or  other  drugs  but  did  not  receive  treatment. 
*  Nine  months  after  treatment. 

§  Including  earnings  from  employment  and  reductions 
in  the  costs  related  to  emergency  department  visits, 
incarceration  and  crime. 

**  Including  inpatient  and  outpatient  hospital  care, 
physicians'  services,  prescription  drugs  and  nursing 
home  care.  Most  of  the  reductions  in  medical 
spending  were  within  Medicaid  expenditures. 


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with  addiction  receiving  general  assistance 
welfare.69  A  more  recent  analysis  in 
Washington  State  of  the  return  on 
investment  from  an  increase  in  addiction 
treatment  for  disabled  adults  enrolled  in 
Medicaid  or  medical  coverage  through  a 
general  assistance  welfare  program  between 
2006  and  2009  found  a  savings  of  $2.07  in 
medical  and  skilled  nursing  facility  expenses 
for  every  dollar  spent  on  treatment'  over  the 
four-year  period.70 

•  A  performance  audit  of  the  costs  and 
savings  to  the  Colorado  Medicaid  Program— 
which  in  2006,  implemented  a  benefit  to 
provide  outpatient  addiction  treatment  for 
services  related  to  tobacco,  alcohol  and 
other  drugs  for  all  Medicaid  beneficiaries- 
found  that  the  program  cost  $2.4  million 
over  the  course  of  three  years  while  medical 
costs  for  patients  receiving  services  under 
this  program  declined  by  approximately  $3.5 
million/  71 

•  A  simulation  of  potential  cost  savings  in  the 
justice  system  demonstrated  that  treating  all 
arrestees  who  are  at  risk  of  addiction  would 
cost  $13.7  billion  and  save  more  than  $46 
billion  (for  every  dollar  spent  on  treatment, 
more  than  three  dollars  in  benefits  accrue). 
Treating  all  arrestees  who  are  "probably 
guilty"5  and  who  are  at  risk  of  addiction 
would  result  in  a  reduction  in  recidivism 
rates  in  the  range  of  16  to  34  percent, 
depending  on  the  modality  of  treatment 
(with  long-term  residential  treatment 
yielding  the  greatest  reduction  in  recidivism, 
roughly  27  to  34  percent).72 


Measured  as  receiving  a  clinical  diagnosis  of 
alcohol  or  other  drug  dependence  or  psychosis, 
receiving  detoxification  services  or  having  been 
referred  for  alcohol  or  other  drug  assessment  by  the 
state  division  of  alcohol  and  substance  abuse. 

*  In  this  study,  treatment  included  outpatient, 
residential  and  opioid  maintenance  therapy  and  case 
management. 

*  Analysis  based  on  available  Medicaid  claims  data, 
not  a  controlled  longitudinal  study. 

§  As  phrased  by  the  authors  of  the  study  who  state 
that  an  admission  of  guilt  generally  is  required  for 
enrollment  in  court-monitored  treatment. 


Addiction  Involving  Nicotine.  One  study 
found  that  24.6  percent  of  adult  depressed 
smokers  who  received  six  sessions  of  mental 
health  counseling  and  up  to  10  weeks  of  nicotine 
replacement  therapy  (NRT)  with  the  patch  were 
abstinent  from  smoking  after  18  months;  the 
total  cost  of  treatment  (smoking  cessation 
services  plus  mental  health  care)  was  $9,580  per 
life  year**  gained.73 

Following  the  implementation  of  Medicaid- 
covered  pharmaceutical  therapy  for  addiction 
involving  nicotine,  Massachusetts  had  a  46 
percent  annual  decrease  in  hospitalizations  for 
heart  attacks  and  a  49  percent  annual  decrease  in 
cases  of  coronary  atherosclerosis. ft  74 

Addiction  Involving  Alcohol.  For  individuals 
with  addiction  involving  alcohol,  a  number  of 
pharmaceutical  interventions  have  been  found  to 
be  cost  effective,  including  medical  management 
with  naltrexone  therapy  and  combined 
naltrexone  and  acamprosate  therapy.75 

Even  among  patients  who  already  have 
developed  an  alcohol-related  illness  (such  as 
alcohol-related  liver  damage  or  psychosis), 
treatment  may  reduce  future  health  care  costs. 
Naltrexone  therapy  is  related  to  less  of  an 
increase  in  health  care  expenditures  for 
individuals  with  alcohol-related  illnesses 
compared  to  a  control  group1*  ($63  increase 
among  naltrexone  recipients  vs.  $814  increase 
among  controls).  Those  in  the  control  group 
were  more  likely  to  have  an  alcohol-related  visit 
to  the  emergency  department  during  the  study 
compared  to  patients  taking  naltrexone  (15 
percent  vs.  nine  percent).76 

Addiction  Involving  Other  Drugs.  One  study 
examined  the  cost  effectiveness  of  providing 


The  cost  of  extending  a  patient's  life  by  one  year  is 
a  common  metric  used  in  cost-effectiveness  studies. 
' 1  There  were,  however,  no  significant  changes  in 
rates  of  hospital  admissions  for  respiratory  conditions 
including  pneumonia,  asthma,  chronic  obstructive 
pulmonary  disease  and  respiratory  failure. 

Individuals  with  the  same  range  of  alcohol-related 
illnesses  who  were  not  prescribed  naltrexone. 


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treatment  to  pregnant  illicit  drug  users  and 
calculated  an  average  net  savings  of  $4,644  per 
mother/infant  pair.77 

An  examination  of  health  care  and  pharmacy 
costs  for  patients  with  addiction  involving 
opioids  in  a  large  U.S.  health  plan  revealed  that 
total  health  care  costs  (including  inpatient, 
outpatient  and  pharmacy  costs)  six-months  post- 
treatment  were  29  percent  lower  for  patients 
who  received  medication  than  for  patients  who 
received  medication- free  treatment  ($10,192  vs. 
$14,353).78 

A  study  of  the  cost  effectiveness  of  short-term 
opioid  replacement  therapy'  compared  to 
detoxification  only  calculated  a  cost- 
effectiveness  ratio  of  $1,376  in  opioid 
replacement  therapy  costs  per  quality-adjusted 
life  year  (QALY).79  Another  study  projected 
that  methadone  maintenance  therapy  costs 
$5,915  for  every  year  of  life  gained.* 80  In  HIV 
populations,  expanding  methadone  maintenance 
capacity  for  heroin  users  is  cost  effective,  at 
$8,200  per  QALY  gained  in  communities  with 
40  percent  HIV  prevalence  among  injection  drug 
users  and  $10,900  per  QALY  gained  in 
communities  with  five  percent  HIV  prevalence 
among  injection  drug  users.81 


Insurance  Coverage  of  Addiction 
Treatment  is  Limited 

Recently-enacted  federal  and  state  parity  laws 
have  expanded  coverage  for  addiction  treatment 
where  offered,  and  the  Patient  Protection  and 
Affordable  Care  Act  (ACA)  holds  potential  for 
further  expansion  of  access  and  benefits. 
However,  insurance  coverage  of  addiction 
treatment  remains  severely  limited  in  both  the 
populations  and  services  that  are  covered.  The 
absence  of  mandated  coverage  in  all  health  plans 
means  that  some  health  plans  may  continue  to 
choose  not  to  provide  coverage  for  addiction 
treatment,  persisting  to  deny  access  to  patients 
who  need  it.83 

Parity  Laws 

Federal  and  state  parity  laws  require  private 
insurers  that  provide  mental  health  and  addiction 
treatment  services  to  provide  them  on  par  with 
medical  services.  In  general,  restrictions  placed 
on  addiction  services  (e.g.,  co-pays,  deductibles) 
cannot  be  more  restrictive  than  restrictions 
placed  on  other  medical  services.84 

Specifically,  while  the  Mental  Health  Parity  Act 
(MHPA),  passed  in  1996,  did  not  apply  to 
addiction  treatment,85  the  2008  Paul  Wellstone 
and  Pete  Domenici  Mental  Health  Parity  and 
Addiction  Equity  Act  (MHPAEA)  was  enacted, 
in  part,  to  address  this  omission.86  The 
MHPAEA  provisions  apply  to: 

•    Plans  sponsored  by  private  and  public  sector 
employers  with  more  than  50  employees  and 
that  include  medical/surgical  and  mental 
health/addiction  benefits;5 


The  use  of  evidence-based  approaches  in 
treatment  will  be  driven  by  policy.  We  need  to  use 
the  payment  system  to  drive  changes  in  practice?2 

-Jeffrey  Samet,  MD 
Professor  of  Medicine  and  Social  Behavior, 
Clinical  Addiction  Research  and  Education 
(CARE)  Program 
Boston  University  School  of  Medicine 


One  week  of  residential  care  followed  by  intensive 
outpatient  (day  treatment)  services  through  labor/ 
delivery. 

'  Patients,  ages  15-21,  received  12  weeks  of 

buprenorphine -naloxone  therapy  and  also  were   

offered  twice-weekly  counseling.  §  Applies  to  plan  years  beginning  on  or  after  July  1, 

*  Assuming  annual  treatment  costs  of  $5,250.  2010. 


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•  Medicaid  managed  care  plans  and 
benchmark/benchmark-equivalent  plans ' 
that  provide  mental  health/addiction 
benefits;  and 

•  State  plans  within  the  Children's  Health 
Insurance  Program  (CHIP).88 

Under  the  law,  plans  that  offer  addiction 
treatment  benefits  cannot  impose  limitations  on 
these  benefits  that  are  more  restrictive  than 
limitations  placed  on  medical  and  surgical 
benefits.1 89 

In  addition  to  the  federal  parity  laws,  49  states 
and  the  District  of  Columbia  have  some  type  of 
parity  law  for  mental  health  services;  at  least  38 
states  include  coverage  addiction  involving 
alcohol  and/or  other  drugs.  While  the  scope  of 
these  laws  varies,  some  are  stronger  than 
MHPAEA.§  90 


This  includes  traditional  and  benchmark/benchmark 
equivalent  managed  care  plans.  In  Medicaid 
benchmark/equivalent  plans'  benefits  are  determined 
by  comparison  to  BlueCross/BlueShield,  state 
employee  benefit  plans,  certain  Health  Maintenance 
Organization  (HMO)  plans  or  benefits  that  include 
the  basic  services  defined  in  Section  1937(b)(2)  of 
the  Social  Security  Act. 
1  The  ACA  extends  certain  MHPAEA  parity 
requirements  to  Medicaid  benchmark  and  benchmark 
equivalent  plans  that  are  not  managed  care  plans  that 
provide  mental  health  or  addiction  treatment  benefits. 
*  The  interim  final  regulations,  which  went  into  effect 
on  April  5,  2010,  address  how  health  plans  must 
comply  with  MHPAEA  and  how  health  plans  may 
define  covered  services  that  are  consistent  with 
current  medical  standards.  The  regulations  define 
classification  of  benefits  (such  as  inpatient,  in- 
network  or  prescription  drug  benefits);  financial 
requirements  (such  as  deductibles  and  out-of-pocket 
maximums);  treatment  limitations  defined  both 
quantitatively  (limits  on  day  visits  or  frequency  of 
treatment  limits)  and  qualitatively  (standards  for 
provider  admission  into  a  network  or  prescription 
drug  formulary  design);  and  how  to  determine 
whether  these  restrictions  comply  with  the  law. 
§  State  parity  laws  generally  fall  into  three  categories: 
(1)  mental  health  parity/equal  coverage  laws  in  which 
insurers  must  provide  the  same  level  of  benefits  for 
addiction  treatment  as  they  do  for  other  health 
conditions;  (2)  minimum  mandated  mental  health 
benefit  laws  in  which  some  coverage  must  be  offered 


A  recent  government  evaluation  found  that  post- 
MHPAEA,  96  percent  of  employers'  plans 
continued  to  offer  both  mental  health  and 
addiction  treatment  services,  two  percent 
continued  to  cover  only  mental  health  services 
and  another  two  percent  discontinued  their 
coverage  of  addiction  treatment  services.  Plans 
also  indicated  that  they  had  reduced  service 
limitations  on  addiction-related  services  after 
MHPAEA.  In  general,  patients'  average  cost- 
sharing  burden  declined  after  the  MHPAEA, 
with  the  exception  of  co-payments  for  office 
visits  which  increased  slightly.91  (Table  8.1) 


Table  8.1 

Employers'  Insurance  Coverage  of  Addiction 
Benefits  Since  Enactment  of  the  MHPAEA 


2008  Plan 
Year 

2010/2011 
Plan  Year 

Employers  including 
addiction  benefits  in 
most  popular  plan 

97% 

97% 

Employers  placing 
limits  on  office  visits 
for  addiction  care 

33% 

8% 

Employers  placing 
limits  on  inpatient 
days  for  addiction  care 

27% 

8% 

Average  office  visit 
copayment 

$25 

$27 

Average  office  visit 
coinsurance 

22% 

19% 

Average  outpatient 
services  copayment 

$39 

$33 

Average  outpatient 
services  coinsurance 

26% 

19% 

Source:  United  States  Government  Accountability 
Office.  (2011).  


Analysis  of  national  data  found  that  in  states 
with  broad  parity  laws  (where  benefits  for  the 
treatment  of  addiction  and  mental  illness  are 
mandated  in  at  least  some  health  plans  and  must 
be  offered  at  parity  with  medical  and  surgical 
benefits),  there  was  a  12.8  percent  increase 


but  disparities  in  level  of  benefits  provided  are 
permitted;  and  (3)  "mandated  offering  laws"  in  which 
an  option  of  coverage  for  addiction  treatment  is 
offered  and,  if  coverage  is  accepted,  benefits  must  be 
equal  with  other  health  benefits. 


-167- 


between  1 992  and  2007  in  total  treatment 
admissions  compared  to  states  with  weak  parity 
laws  (in  which  parity  laws  were  absent  or  did 
not  include  addiction  treatment  services).  In 
comparison,  in  states  with  limited  parity  laws  (in 
which  parity  was  mandated  but  with  limitations 
such  as  applying  to  certain  groups  or  a  limited 
number  of  health  plans),  there  was  only  a  4.7 
percent  increase  (compared  to  states  with  weak 
parity  laws)  in  addiction  treatment  admissions 
during  this  time.92 

Among  adolescents  who  received  both  an 
addiction  and  psychiatric  diagnosis,  those  living 
in  a  state  with  a  parity  law  expanding  coverage 
for  addiction  treatment  are  4.5  times  as  likely  to 
be  diagnosed  with  addiction  and  3.2  times  as 
likely  to  receive  treatment  as  adolescents  in 
states  without  such  parity  laws.93 

The  Patient  Protection  and  Affordable 
Care  Act  of  2010 

The  Patient  Protection  and  Affordable  Care  Act 
(ACA)  of  20 1 0  was  enacted  to  expand  access  to 
insurance  for  the  uninsured,  to  make  health  care 
more  affordable  and  to  reform  health  care 
delivery  systems  to  improve  quality.94  The 
federal  government  estimates  that  the  ACA 
could  expand  coverage  for  addiction  treatment 
to  an  additional  4.8  million  Americans  if 
coverage  is  offered  at  parity  with  other  health 
benefits.* 95 


plans  as  part  of  an  "essential  health  benefit" 
package.97  The  ACA  also  extends  requirements 
of  MHPAEA  to  some  health  plans  to  which  the 
law  did  not  previously  apply/  98 

One  main  goal  of  the  ACA  is  to  increase  the 
number  of  people  who  have  health  insurance  by 
making  more  people  eligible  for  Medicaid,99 
allowing  individuals  who  do  not  have  insurance 
through  their  job  to  obtain  insurance  in  state 
exchanges  (transparent  and  competitive 
marketplaces),  offering  them  income-based  tax 
credits  and  subsidies100  and  allowing  young 
adults  under  age  26  to  remain  covered  by  their 
parents'  insurance  plan.5  101 

The  ACA  also  attempts  to  change  the  way  health 
care  is  delivered  to  improve  quality  and  integrate 
addiction  treatment  into  medical  care,  for 
example  through  demonstration  projects  like 
Medicaid  health  homes,  where  teams  of  health 
professionals  care  for  individuals  with  chronic 
conditions  including  addiction;102  accountable 
care  organizations  (ACOs),  in  which  groups  of 
health  professionals  coordinate  services  for 
Medicare  fee-for-service  patients;103  and  through 
temporary  funding  to  expand  the  role  of 
community  health  centers.104  If  these  initiatives 
are  successful  and  become  common  practice, 
they  will  help  to  integrate  the  treatment  of 
addiction  into  mainstream  medical  practice  and 
expand  the  use  of  pharmaceutical  therapies.105 


The  ACA  has  the  potential  for  increasing  access 
to  addiction- related  services  by  (1)  increasing 
the  number  of  people  who  are  covered  by  health 
insurance96  and  (2)  requiring  that  addiction 
treatment  benefits  be  offered  by  certain'  health 


This  estimate  was  for  those  who  buy  coverage  in  the 
individual  market,  and  while  these  plans  must 
provide  some  form  of  addiction  treatment  as  part  of 
Essential  Health  Benefits,  states  have  not  yet  defined 
their  Essential  Health  Benefits.  It  is  unclear  how 
many  states  will  include  the  full  range  of  necessary 
services  for  addiction  treatment  in  their  definition. 
f  Including  new  small  fully-insured  or  self-insured 
plans,  new  individual  market  health  plans,  qualified 
health  plans  (as  defined  by  the  ACA),  Basic  Health 
Programs  and  Medicaid  benchmark/equivalent  plans. 


*  The  ACA  requires  that  qualified  health  plans 
offered  through  the  exchanges,  individual  (non- 
group)  market  plans  and  Medicaid  non-managed  care 
benchmark  and  benchmark-equivalent  plans  comply 
with  MHPAEA. 

§  Even  if  they  are  married,  in  school  or  eligible  to 
enroll  in  their  employer's  plan.  Plans  that  existed  on 
March  23,  2010  do  not  have  to  offer  dependent 
coverage  until  2014  if  the  dependent  is  eligible  for 
employer-sponsored  insurance. 


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Gaps  in  Coverage  within  Public  and 
Private  Insurance  Plans  Continue  to 
Impede  Comprehensive  Addiction  Care 

Screening  and  Interventions  for  Risky 
Substance  Use.  Recent  developments  in 
Medicare  and  Medicaid  reimbursement  have 
begun  to  remove  some  of  the  cost  barriers  that 
health  professionals  faced  in  routinely  screening 
their  patients  for  risky  use  of  addictive 
substances  and  conducting  early  interventions 
when  necessary.106 

For  example,  the  U.S.  Department  of  Health  and 
Human  Services'  Centers  for  Medicare  and 
Medicaid  Services  (CMS)  adopted  Medicaid 
billing  codes  for  screening  and  brief  intervention 
services;  in  January  2007,  these  codes  became 
effective.107  The  Medicaid  codes  cover  these 
services  related  to  alcohol  and  other  drugs 
(excluding  nicotine).108  These  codes  are 
available  for  health  care  providers  in  individual 
states  to  use  but  there  is  no  requirement  for 
providers  to  use  the  codes.  Individual  states 
determine  which  services  are  reimbursed  and,  to 
be  operational,  states  have  to  enable  the  billing 
codes;  however,  many  have  not  done  so.* 109 
With  regard  to  smoking,  the  only  screening 
services  that  states  explicitly  are  required  to 
provide  are  those  that  fall  under  the  Early  and 
Periodic  Screening,  Detection  and  Treatment 
(EPSDT)  Program— the  child  health  component 
of  Medicaid  which  is  required  for  each  state  to 
finance  appropriate  and  necessary  pediatric 
services,  including  tobacco  cessation  services 
for  youth;  as  of2000,T  15  states  explicitly 
require  providers  to  screen  youth  for  tobacco 
use.110  (See  next  section  on  treatment  for 
information  about  coverage  for  smoking 
cessation  services.) 

In  2008,  CMS  adopted  Medicare  billing  codes 
for  structured  assessments1  and  brief 
intervention  services  related  to  the  risky  use  of 
alcohol  and  other  drugs  (excluding  nicotine)  for 


And  these  codes  do  not  cover  screening  and 
intervention  services  for  all  addictive  substances. 
'  Most  recent  available  data. 

*  Structured  assessments  involve  the  use  of  validated 
tools  such  as  AUDIT  or  DAST  (see  Appendix  H). 


patients  who  show  signs/symptoms  of 
substance-related  problems.111  These  services 
were  reimbursed  only  when  reasonable  and 
necessary  to  diagnose  or  treat  illness  or  injury.112 
In  October  201 1,  CMS  determined  that 
Medicare  would  provide  coverage  in  primary 
care  settings8  for  preventive  annual  alcohol 
screening   of  all  patients  and  up  to  four  brief, 
face-to-face  interventions  for  Medicare 
beneficiaries  who  screen  positive  for  risky 
alcohol  use  but  who  do  not  meet  clinical  criteria 
for  addiction  involving  alcohol.113  Medicare 
does  not  reimburse  for  population-wide 
screening  and  brief  interventions  to  address  the 
risky  use  of  illicit  and  prescription  drugs  because 
it  is  not  yet  recommended  by  the  U.S. 
Preventive  Services  Task  Force  (see  Chapter 
iV).tt  114  Although  there  are  no  specific 
Medicare  codes  for  general  tobacco  use 
screening,  questions  about  tobacco  use  are 
considered  part  of  the  medical  history  to  be 
collected,  for  example,  during  the  Initial 
Preventive  Physical  Examination  for  those  new 
to  Medicare.115  As  of  August  2010,  Medicare 
does  cover  preventive  tobacco  cessation 
counseling  for  smokers  who  do  not  present  with 
signs  or  symptoms  of  tobacco-related  disease. 
The  benefit  includes  two  individual  tobacco 
cessation  counseling  attempts  per  year,  with 
each  attempt  consisting  of  up  to  four  sessions.116 

Despite  the  facts  that  the  American  Medical 
Association  (AMA)  has  published  Current 
Procedural  Terminology  (CPT)  codes  for 
screening  for  tobacco  use**  117  and  risky  use  of 
alcohol  and  other  drugs118  and  that  most  private 
insurance  plans  cover  these  services,119  patients 
are  not  routinely  screened  for  risky  use  or 
provided  brief  interventions  if  indicated.  A 
2009  survey  found  that  very  few  claims  have 
been  paid  by  commercial  insurance  plans  for 


s  Including  outpatient  hospital  settings. 
**  But  not  for  other  substances.  Medicare  allows 
providers  to  choose  any  screening  tool  that  is 
appropriate  for  their  clinical  population  and  setting. 
' 1  Medicare  does  cover  structured  assessments  to 
evaluate  and  provide  interventions  for  patients  who 
exhibit  symptoms  of  addiction  involving  drugs. 

CPT  codes  for  tobacco  screening  include  the  codes 
for  "health  and  behavior  assessment"  and  other 
preventive  medicine  services. 


-169- 


alcohol  and  other  drug  screening  and  brief 
intervention  services.120  Although  76  percent  of 
smokers  in  commercial  health  plans  reported 
being  advised  by  their  physician  to  stop  smoking 
in  a  2008  survey;  only  half  recalled  being 
advised  about  smoking  cessation  strategies  or 
medications.121 

The  ACA  was  designed  to  increase  the  number 
of  individuals  covered  under  Medicaid  and 
commercial  insurance,*  122  but  also  allows  states 
facing  budget  deficits  to  scale  back  eligibility 
under  certain  circumstances. f  123  Because  of 
economic  constraints,  states  appear  to  be  cutting 
back  on  health  services  rather  than  assuring 
access  to  these  services.1 124 

An  additional  resource  problem  that  stands  in 
the  way  of  screening  and  early  interventions  is  a 
legal  statute  dating  back  to  1947,  the  Uniform 
Accident  and  Sickness  Policy  Provision  Law 
(UPPL)}15  Under  the  UPPL,  insurers  can  deny 
payment  for  treatment  of  injuries  sustained  by  a 
person  under  the  influence  of  alcohol  or  other 
drugs.§  126  In  states  that  adopted  UPPL,  EDs  and 
trauma  centers  might  not  screen  for  risky 
substance  use  because  reimbursement  for  the 
emergency  or  trauma  services  they  provide 
could  be  denied;  as  a  result,  critical 
opportunities  for  intervention  are  missed. 127 
Because  of  the  barriers  the  UPPL  imposes  to 


The  ACA  mandates  no  co-pay  in  private  insurance 
and  self-insured  plans  for  alcohol  screening  and 
counseling;  alcohol  and  other  drug  use  assessments 
for  adolescents;  tobacco  use  screening  for  all  adults; 
and  cessation  interventions  for  tobacco  users. 
'  States  are  permitted  to  scale  back  eligibility  if  they 
have  expanded  their  Medicaid  programs  to  non- 
pregnant, non-disabled  adults  with  incomes  over  133 
percent  of  the  poverty  level. 

*  At  least  3 1  states  have  implemented  cuts  that  will 
restrict  eligibility  for  health  insurance  programs 
and/or  access  to  health  care  services. 
§  The  law  originally  was  adopted  to  control  insurance 
costs  at  a  time  when  little  knowledge  was  available 
about  addiction  and  when  access  to  treatment  was 
limited.  The  statute  states:  "The  insurer  shall  not  be 
liable  for  any  loss  sustained  or  contracted  in 
consequence  of  the  insured's  being  intoxicated  or 
under  the  influence  of  any  narcotic  unless 
administered  on  the  advice  of  a  physician." 


needed  screening  and  interventions  for  risky 
substance  use,  the  AMA  has  been  working  to 
overturn  the  law  and  prohibit  other  state  laws 
modeled  on  it.**  128  As  of  January  201 1,  25 
states  still  have  the  UPPL  or  a  history  of  court 
decisions  that  permit  insurers  to  use  an  alcohol 
exclusion  to  deny  payment  for  treatment;  1 6 
states  and  the  District  of  Columbia  prohibit 
denial  of  benefits."  129  A  similar  legal  provision 
allows  many  states  to  deny  disability  payments 
or  workers'  compensation  to  individuals  harmed 
while  under  the  influence  of  alcohol  or  while 
participating  in  an  illegal  act,  such  as  driving 
under  the  influence.130 

Treatment  for  Addiction.  Current  coverage  of 
addiction  treatment  is  not  designed  to  prevent 
and  treat  the  disease  effectively.  There  is 
considerable  variability  in  coverage  within  and 
among  public  and  private  insurance  plans  which 
poses  significant  barriers  to  treatment 
accessibility. 

Medicaid.  The  Medicaid  program  is  the  major 
public  health  coverage  program  for  low-income 
Americans.131  With  the  exception  of  the  ACA's 
"essential  health  benefits"  requirement/* 
addiction  treatment  services  are  not  federally 
mandated  in  Medicaid,132  nor  are  any  addiction 
treatment  services  that  are  eligible  for 
reimbursement  defined  at  the  federal  level.133 
However,  states  may  provide  addiction-related 
services  under  several  of  the  mandatory  benefit 
categories: 

•  Physician  services; 134 

•  Inpatient  services  provided  in  a  general 
hospital,  such  as  inpatient  detoxification,135 
but  not  including  room  and  board  charges  in 


In  2001,  the  National  Association  of  Insurance 
Commissioners,  which  originally  adopted  the  UPPL 
as  a  model  law  in  1947  and  encouraged  states  to 
implement  it,  reversed  their  position  and 
recommended  the  repeal  of  the  UPPL.  Since  that 
time,  several  organizations  along  with  the  AMA  have 
pledged  support  for  repealing  the  UPPL. 
' r  Other  states  do  not  explicitly  permit  or  prohibit 
alcohol  exclusion  provisions. 
M  Applies  to  Medicaid  benchmark/equivalent  plans. 


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residential  specialty  treatment  settings  or 
inpatient  care  for  patients  ages  22-  to  64- 
years  old  in  institutions  for  mental 
disease;136  and 

•  Outpatient  hospital  care,*  including 
detoxification,  individual,  group  or  family 
counseling  and/or  psychotherapy,  and 
diagnosis,  treatment,  assessment  and 
medication  management.137 

Optional  benefit  categories  under  which 
addiction-related  treatment  services  also  may  be 
provided  include: 

•  Outpatient  rehabilitation  services,  including 
diagnostic  and  treatment  services.  States 
providing  optional  benefits  under  Medicaid 
often  choose  this  option  since  it  does  not 
require  services  to  be  provided  under  the 
direction  of  a  physician  and  instead  permits 
the  delivery  of  services  including  mutual 
support  by  community  paraprofessionals  and 


•  Clinic  services;  and 

•  Case  management  services.140 

Last,  states  may  provide  addiction  treatment 
services  as  part  of  a  Medicaid  managed  care 
waiver  program.1  141 

Because  state  Medicaid  plans  vary  widely  in 
their  eligibility  requirements  and  benefits, 
individuals  have  substantially  different  access  to 
care  depending  on  the  state  in  which  they  live. 
Some  states  cover  a  broad  range  of  addiction- 
related  services;  others  provide  only  a  few  and 

i  •  142 

two  states  cover  no  such  services. 

State  Medicaid  programs  also  distinguish 
between  services  offered  for  addiction  treatment 


Several  states  specifically  exclude  addiction 
treatment  from  the  outpatient  services  benefits  and 
some  place  limits  on  the  services  such  as  number  of 
visits  per  year. 

'  A  2006  survey  found  that  3 1  states  offer  addiction 
treatment  through  a  managed  care  waiver  program. 


involving  nicotine  and  treatment  involving 
alcohol  and  other  drugs. 

With  regard  to  smoking,  Medicaid  plans  are 
required  to  provide  tobacco  cessation  counseling 
and  pharmaceutical  treatments  to  pregnant 
women,  children  and  adolescents.  States  are 
free  to  choose  whether  or  not  to  include  tobacco 
cessation  benefits  for  other  enrollees.143  In 
2009,  1 8  states  covered  individual  counseling 
for  all  Medicaid  enrollees,  seven  states  covered 
counseling  only  for  enrollees  in  some  programs 
(fee-for-service  or  managed  care)  and  six  states 
covered  it  only  for  pregnant  women.  Eight 
states  covered  group  counseling  for  all  Medicaid 
enrollees,  five  covered  group  counseling  only 
for  enrollees  in  some  programs  (fee  for  service 
or  managed  care)  and  five  states  covered  group 
counseling  for  pregnant  women  only.  As  of 
2009,  34  states  covered  the  nicotine  patch  for  all 
Medicaid  enrollees,  33  covered  bupropion,  32 
covered  nicotine  gum,  32  covered  varenicline, 
28  covered  nicotine  nasal  spray,  27  covered 
nicotine  inhalers  and  25  covered  nicotine 
lozenges.144  As  of  201 1,  six  state  Medicaid 
programs  provide  comprehensive  coverage  for 
smoking  cessation  treatments  for  all  Medicaid 
enrollees,  while  five  state  Medicaid  programs 
provide  no  coverage  for  cessation  treatment  for 
any  enrollees.145 

Medicare.  Medicare  is  a  federally-funded 
system  for  financing  health  care  for  U.S.  citizens 
ages  65  and  older  and  people  under  age  65  with 
certain  disabilities.146  Medicare  covers  the 
following  services,  when  medically  necessary: 

•  Inpatient  hospital  services  for  detoxification 
for  addiction  involving  alcohol  and 
outpatient  services  for  detoxification  for 
addiction  involving  drugs  other  than 

147 

nicotine; 

•  Inpatient  rehabilitation  treatment  for 
addiction  involving  alcohol,  controlled 
prescription  drugs  and  illicit  drugs  in  an 
acute  care  or  psychiatric  hospital;148 

•  Outpatient  hospital-based  diagnostic  and 
therapeutic  services  for  treatment  of 


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addiction  involving  alcohol,  and  outpatient 
hospital  services  involving  detoxification, 
rehabilitation  and  treatment  for  addiction 
involving  drugs  other  than  nicotine;149 

•  Clinic-based  treatment  services  for  addiction 
involving  alcohol  and  detoxification  services 
for  addiction  involving  opioids,  under 
physician  supervision;150  and 

•  Tobacco  cessation  counseling  from  a 
qualified  physician  or  practitioner  for  all 
smokers  and  tobacco  cessation  medications 
prescribed  by  a  physician.151 

Methadone  maintenance  therapy  also  is  covered 
on  an  outpatient  basis,  but  only  when  indicated 
for  pain,  and  in  hospitals  for  treatment  of 
addiction  involving  opioids.152 
Differences  in  copayments  for  outpatient 
addiction  treatment  and  other  outpatient  services 
will  be  phased  out  by  20 14. 153 

Private  Health  Insurers.  Historically,  private 
health  insurers  have  provided  less  coverage  for 
the  treatment  of  addiction  than  for  other  health 
conditions  by  setting  lower  annual  or  lifetime 
limits  on  benefits,'  covering  fewer  inpatient  days 
or  outpatient  visits  and  increasing  cost  sharing 
through  higher  deductibles  and  copayments.154 
A  survey  of  private  health  plans  found  that, 
while  only  1 6  percent  of  private  insurance 
offerings  imposed  lifetime  limits  on  addiction 
treatment,  94  percent  had  annual  limits  for 
outpatient  services  and  89  percent  had  annual 
limits  for  inpatient  services.  Private  insurance 
offerings  were  more  likely  to  limit  visits 
(outpatient)  or  days  (inpatient)  than  to  limit 
spending.155 


Medicare  covers  two  individual  cessation 
counseling  attempts  per  year,  and  each  attempt  may 
include  up  to  four  sessions. 
'  Annual  limits  are  caps  that  insurers  place  on  the 
benefits  an  enrollee  is  entitled  to  each  year.  Limits 
can  apply  to  particular  services  (e.g., 
hospitalizations),  number  of  visits  or  dollar  amount 
of  covered  services.  Lifetime  limits  are  caps  on 
expenditures,  on  specific  services  or  both  during  an 
individual's  lifetime. 


Children's  Health  Insurance  Program  ( CHIP). 
Under  CHIP,  formerly  the  State  Children's 
Health  Insurance  Program  (SCHIP),  states  are 
entitled  to  federal  matching  funds  up  to  specified 
limits  to  finance  health  care  for  low-income 
children1  who  do  not  qualify  for  Medicaid.156 
States  can  provide  benefits  related  to  substance 
use  and  addiction  under  CHIP  by  expanding 
children's  eligibility  under  Medicaid,  by 
creating  a  separate  insurance  program  or  through 
some  combination  of  these  approaches.  States 
that  opt  simply  to  expand  their  Medicaid 
programs  are  required  to  follow  the  rules  and 
requirements  of  Medicaid.157  States  that  provide 
benefits  by  creating  unique  CHIP  programs 
(outside  of  Medicaid)  must  provide  a  benefits 
package  equivalent  to  one  of  several 
"benchmark"  insurance  plans. §  158  States  have 
latitude  in  designing  their  CHIP  program.159  A 
2000  study  found  that  almost  all  states  provided 
at  least  one  of  detoxification,  inpatient/ 
residential  or  outpatient  services,  though  many 
states  imposed  annual  limits  (e.g.,  20  or  60  visits 
per  year)  or  lifetime  benefit  limits  (e.g.,  $16,000 
or  $20,000). 160 

Gaps  in  Addiction  Care  Coverage  Within 
Parity  and  Health  Reform  Initiatives.  With 
regard  to  federal  parity  laws,  MHPAEA  includes 
an  exemption  if  the  financial  burden  of 
implementing  the  law  is  too  great,**  161  and  small 
employers  (with  less  than  50  employees)  are 
exempt  from  the  law  completely.162  Under 
MHPAEA,  insurance  plans  may  cap  services 


1  Through  waivers,  states  may  expand  CHIP 
eligibility  to  pregnant  women,  low-income  parents 
and  adults  without  children. 
§  Such  as  the  Blue  Cross/Blue  Shield  Standard 
Option  Service  Benefit  Plan  offered  under  the 
Federal  Employees  Health  Benefits  Program 
(FEHBP),  a  plan  that  is  available  to  the  state's 
employees  or  a  plan  offered  by  the  HMO  with  the 
largest  enrollment  in  the  state  outside  of  Medicaid. 
States  also  may  use  a  benefits  package  that  is 
actuarially  equivalent  to  one  of  the  benchmark  plans, 
an  already  existing  state-funded  plan  or  any  other 
plan  approved  by  the  federal  government. 

Health  plans  are  exempt  if  complying  with  the  law 
results  in  a  cost  increase  of  greater  than  two  percent 
in  the  first  plan  year  and  greater  than  one  percent  in 
subsequent  years. 


-172- 


(e.g.,  number  of  visits  per  year)  as  long  as  the 
caps  are  equivalent  to  those  placed  on  medical 
services.163  Placing  blanket  limitations  on 
allowed  visits  or  length  of  stay,  however,  does 
not  accord  with  best  practices  for  treating  cases 
of  addiction  that  are  chronic  and  relapsing.164 

Challenges  to  implementing  MHPAEA  in 
practice  include  a  lack  of  education  among 
medical  professionals  in  how  to  screen, 
intervene  and  treat  addiction  and  a  lack  of 
addiction  physician  specialists.165 

With  regard  to  state  parity  laws,  self-insured 
employer-sponsored  health  plans  are  exempt 
from  state  regulation  under  the  federal 
Employee  Retirement  Income  Security  Act 
(ERISA)  of  1974. 166  Furthermore,  coverage  for 
mental  health  and  addiction  services  varies 
dramatically  by  state,  depending  on  the  strength 
of  the  state's  parity  law. 

With  regard  to  the  ACA,  despite  the 
improvements  in  treatment  coverage  that  will 
arise  from  its  passage,  many  limitations  remain 
both  in  policy  and  practice.  Its  impact  on 
treatment  access  remains  to  be  seen  since  many 
of  the  provisions  of  the  law  have  not  yet  taken 
effect.  For  example,  the  expansion  of  Medicaid 
as  a  payer  likely  will  result  in  reductions  in 
federal  and  state  grants  for  residential  care 
(which  is  not  covered  by  Medicaid).  As  a  result, 
care  may  transition  toward  outpatient 
treatment167  which  may  be  inadequate  in  some 
cases,  such  as  for  treating  patients  with  more 
severe  addiction. 

Expanding  access  to  insurance  is  necessary  but 
alone  is  not  sufficient  to  expand  access  to  care. 
In  2006,  Massachusetts  enacted  health  care 
reform  legislation  similar  to  the  ACA  which, 
among  other  things,  established  universal  health 
insurance  through  individual  mandates  to 
purchase  insurance  and  government  subsidies.168 
In  the  years  following,  addiction  treatment 
admission  rates  did  not  increase  significantly. 
Despite  the  fact  that  the  total  uninsured 
population  dropped  to  three  percent,  a  large 
number  (23-30  percent)  of  patients  with 
addiction  remained  uninsured,  either  due  to  non- 
compliance with  the  mandate  to  obtain 


insurance,  inability  to  pay  even  with  subsidies  or 
logistical  barriers  such  as  lack  of  documentation 
or  a  stable  home  address.  For  some  of  those 
who  were  successful  in  becoming  insured,  co- 
insurance and  co-payments  rendered  treatment 
unaffordable.169  Furthermore,  expanding 
insurance  coverage  does  not  automatically 
translate  into  expanded  screening  and  diagnosis 
by  health  professionals  or  capacity  to  treat  large 
numbers  of  newly-insured  patients. 
Similarly,  requiring  parity  for  addiction  benefits 
in  Federal  Employee  Health  Benefit  (FEHB) 
plans  did  not  result  in  increased  treatment  rates. 
An  analysis  of  nine  large  FEHB  plans  in  the  two 
years  before  and  after  the  parity  requirement 
found  that  the  number  of  new  diagnoses  of 
addiction  increased;  however,  utilization  rates 
for  addiction  treatment  benefits  were 
unaffected.170 

The  ACA  includes  1 0  categories  of  essential 
health  benefits  (EHB)— including  addiction 
treatment-that  must  be  provided  by  newly- 
created  individual  and  small  group  plans.171  Yet 
rather  than  defining  what  these  services  must 
include,  the  federal  government  has  proposed 
that  each  state  design  its  own  EHB  package,*  172 
meaning  that  benefits  will  vary  across  states. 
Furthermore,  the  EHB  provisions  do  not  apply 
to  self-insured  group  health  plans,  large  group 
market  health  plans  or  already  existing  small  and 
individual  market  ("grandfathered")  health 
plans.173  The  provisions  that  would  expand 
coverage  and  require  EHBs  do  not  go  into  effect 
until  2014.174 

Efforts  to  control  spending  and  legal  challenges 
may  limit  some  intended  effects  of  the  ACA. 
States  may  respond  to  fiscal  challenges  by 
attempting  to  control  costs  in  their  Medicaid 
programs  by  cutting  services.175  Moreover,  the 
ACA  faces  challenges  in  the  U.S.  Supreme 


*  Within  limits-the  plan  must  be  comparable  to  a 
benchmark  plan:  (1)  the  largest  plan  by  enrollment  in 
any  of  the  three  largest  small  group  insurance 
products  in  the  state's  small  group  market;  (2)  any  of 
the  largest  three  state  employee  health  benefit  plans 
by  enrollment;  (3)  any  of  the  largest  three  national 
FEHBP  plan  options  by  enrollment;  or  (4)  the  largest 
insured  commercial  non-Medicaid  HMO  operating  in 
the  state. 


-173- 


Court  over  two  provisions  that  would  expand 
coverage:  the  Medicaid  expansion  and  the 
requirement  for  individuals  not  covered  under 
public  programs  or  by  employer-sponsored 
insurance  to  purchase  insurance;  the  Court's 
decision  would  have  implications  not  just  for 
these  provisions  but  for  other  parts  of  the  law  as 


For  example,  if  the  Supreme  Court  decides  that  the 
individual  mandate  is  unconstitutional  and  not 
severable  from  the  rest  of  the  legislation,  the  entire 
ACA  would  be  struck  down.  If  it  is  deemed 
unconstitutional  and  severable,  then  the  prohibitions 
against  excluding  patients  with  pre-existing 
conditions  and  charging  higher  premiums  based  on  a 
person's  medical  history  also  might  be  invalidated. 


Chapter  IX 

The  Education,  Training  and  Accountability  Gap 


Compounding  the  profound  gap  between  the 
need  for  prevention,  intervention,  treatment  and 
disease  management  for  addiction  and  the 
receipt  of  such  care  is  the  enormous  deficit  of 
trained  providers;  there  is  a  wide  gulf  between 
existing  knowledge  about  addiction  and  its 
prevention  and  treatment  and  the  education  and 
training  received  by  those  who  provide  or  should 
provide  care.  In  spite  of  the  evidence  that  risky 
use  of  addictive  substances  is  a  public  health 
problem  and  addiction  is  a  disease: 

•  Most  health  professionals*  are  not 
sufficiently  trained  to  educate  patients  about 
risky  use  and  addiction,  conduct  screening 
and  interventions  for  risky  use  or  diagnose 
and  treat  addiction; 

•  Most  of  those  who  currently  are  providing 
addiction  treatment  are  not  medical 
professionals  and  are  not  equipped  with  the 
knowledge,  skills  or  credentials  necessary  to 
prove  the  full  range  of  evidence-based 
services  to  address  addiction  effectively;*  1 
and 


The  term  "health  professional"  as  used  in  this  report 
includes  medical  professionals  (physicians,  physician 
assistants,  nurses  and  nurse  practitioners,  dentists, 
pharmacists)  and  graduate-level  clinical  mental 
health  professionals  (psychologists,  social  workers, 
counselors).  All  health  professionals  can  be  trained 
to  educate  patients  about  risky  use  and  addiction  and 
screen  for  these  conditions;  brief  interventions  also 
can  be  conducted  by  appropriately  trained  health 
professionals.  Diagnosis  and  treatment  requires  a 
trained  physician  with  the  exception  of  psychosocial 
treatments  which  can  be  provided  by  trained 
graduate-level  clinical  mental  health  professionals 
working  with  a  managing  physician. 
1  The  National  Quality  Forum  (2005)  defines 
evidence-based  addiction  care  to  include:  screening, 
brief  interventions,  treatment  planning,  psychosocial 
interventions,  pharmaceutical  therapy,  retention 
strategies  and  chronic  care  management.  Effective 
implementation  requires  particular  skills  and  training. 


-175- 


•    Addiction  treatment  facilities  and  programs 
are  not  adequately  regulated  or  held 
accountable  for  providing  treatment 
consistent  with  medical  standards  and 
proven  treatment  practices.2 

Further  complicating  the  education,  training  and 
accountability  gap  in  addiction  treatment  is  the 
fact  that  there  are  no  national  standards;  instead, 
there  is  considerable  inconsistency  among  states 
in  the  regulation  of  individual  treatment 
providers  and  of  the  programs  and  facilities  that 
provide  addiction  treatment  services.* 

For  just  about  all  known  diseases  other  than 
addiction,  treatment  is  provided  within  a  highly- 
regulated  health  care  system.  In  contrast, 
patients  with  the  disease  of  addiction  are 
referred  to  a  broad  range  of  providers  largely 
exempt  from  medical  training  and  standards  (for 
many  of  whom  the  main  qualification  may  be 
that  they  themselves  have  a  history  of  addiction) 
who  work  within  a  fragmented  system  of  care 
with  inconsistent  regulatory  oversight. 

The  Size  and  Shape  of  the 
Addiction  Treatment  Workforce 

Given  the  extensive  prevalence  of  addiction  in 
the  U.S.  and  the  frequently  extensive  treatment 
needs  of  individuals  with  addiction,  there  is  a 
significant  shortage  of  qualified  addiction 
treatment  providers.3  According  to  data 
collected  from  1996  to  1997,  there  are  134,000 
full-time  staff  and  201,000  total  staff  (including 
part-time  and  contract  staff)  working  in 
addiction  treatment. '  Only  a  small  proportion  of 
these  workers,  however,  have  medical  training.4 


Trained  medical  professionals  and  other 
graduate-level  health  professionals  are  less 
likely  than  other  types  of  providers  to  work  full- 
time  in  addiction  treatment;  rather,  staff 
members  with  higher  levels  of  education  are 
more  likely  to  be  hired  on  a  contract/part-time 
basis.5  A  nationally  representative  survey  of 
addiction  treatment  facilities  found  that  one- 
quarter  of  the  program  directors  were  not  full- 
time  employees;  only  two  of  the  programs 
surveyed  were  directed  by  a  physician;  54 
percent  employed  a  part-time  physician;  less 
than  1 5  percent  employed  a  nurse;  and 
psychologists  and  social  workers  rarely  were  on 
staff.6  An  older  study1  found  that  medical 
professionals  and  graduate-level  counselors  each 
made  up  only  about  17  percent  of  the  full-time 
staff  of  addiction  treatment  facilities  and  that 
only  12.8  percent  of  facilities  had  a  physician  on 
staff  full  time.§  7  Another  study  found  that  more 
than  a  third  of  clinical  supervisors  lack  any  type 
of  graduate  degree.8 

Unlike  patient  care  in  the  mainstream  medical 
system,  which  is  delivered  by  highly  educated 
and  trained  professionals,  the  staff  primarily 
responsible  for  patient  care  in  addiction 
treatment  facilities  is  comprised  largely  of 
addiction  counselors,  many  of  whom  while 
highly  dedicated  to  addiction  care  have  only  a 
bachelor's  degree  or,  in  some  cases,  no  post- 
high  school  education.9  The  Bureau  of  Labor 
Statistics  reports  that  there  were  76,600 
addiction  counselors  in  201 1."  10  One  study 
found  that  50  percent  of  facilities  have  full-time 
counselors  on  staff  who  have  no  degree;  58.5 
percent  have  a  bachelor's  level  counselor,  61.9 
percent  have  a  master's  level  counselor  and  12.0 
percent  have  a  doctorate  level  counselor. 1 1 


With  the  notable  exception  of  the  regulation  of 
medication-assisted  therapy  for  addiction  involving 
opioids. 

*  This  estimate  includes  physicians,  registered  nurses, 
other  medical  personnel,  doctoral  level  counselors, 
master's  level  counselors,  counselors  with  other 
degrees,  non-degreed  counselors  and  other  staff. 
Data  on  the  numbers  of  professionals  who  currently 
are  providing  some  type  of  addiction  treatment  are 
not  available. 


*  Data  are  from  1996/1997. 

§  25.8  percent  had  a  full-time  registered  nurse  and 

17.5  percent  had  other  full-time  medical  staff. 

Addiction  counselors  are  those  who  "counsel  and 
advise  individuals  with  alcohol,  tobacco,  drug  or 
other  problems  such  as  gambling  and  eating 
disorders.  May  counsel  individuals,  families  or 
groups  or  engage  in  prevention  programs."  This 
estimate  excludes  social  workers,  psychologists  and 
mental  health  counselors  who  provide  these  services. 


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Even  among  physicians,  who  constitute  the 
group  most  qualified  to  treat  patients  with  the 
medical  disease  of  addiction,  required  training  in 
addiction  is  minimal.12  And  there  is  a  severe 
shortage  of  physicians  with  expertise  in 
addiction  treatment  via  the  medical  specialty 
fields  of  addiction  medicine  and  addiction 
psychiatry.13 

The  American  Medical  Association  (AMA) 
estimates  that  of  the  985,375  active  physicians, 
there  are  only  582  addiction  physician 
specialists:  227  addiction  medicine  physicians 
and  355  addiction  psychiatrists  —the  two 
medical  sub-specialties  specifically  trained  in 
addiction  science  and  its  treatment— totaling 
6/100ths  of  one  percent  of  all  active 
physicians.14  However,  according  to  the 
American  Board  of  Addiction  Medicine 
(ABAM),  these  estimates  are  low  since  they 
come  from  a  voluntary,  self-report  survey  in 
which  physicians  who  choose  to  respond  are 
asked  to  indicate  their  specialty  and  typically 
mark  the  field  of  their  primary  board 
certification  rather  than  their  subspecialty.15 

Although  there  are  no  recent  data  identifying  the 
actual  number  of  practicing  specialists  in 
addiction  medicine  or  addiction  psychiatry, 
ABAM  has  certified  2,584  addiction  medicine 
specialists  and  estimates  that  the  number  of full- 
time  practicing  addiction  medicine  specialists 
may  be  about  five  times  the  amount  of  the  AMA 
estimate— approximately  1,200.'  16  This  estimate 
still  falls  far  short  of  the  estimated  minimum  of 
6,000  full-time  addiction  medicine  specialists 
currently  needed  to  meet  addiction  treatment 
demands.17  Even  this  projection  of  workforce 
need  in  addiction  medicine  may  underestimate 
the  need  in  several  ways:  (1)  it  does  not  include 
adolescents;  (2)  it  does  not  include  addiction 
involving  nicotine;*  (3)  it  does  not  include 
institutionalized  individuals;  (4)  it  assumes  that 
only  those  who  meet  clinical  criteria  for 


Based  on  data  from  2010. 
1  Data  on  the  number  of  practicing  addiction 
medicine  specialists  who  are  involved  directly  in 
patient  care  are  not  available. 
*  Unless  addressed  in  the  context  of  addiction 
involving  alcohol  or  other  drugs. 


substance  dependence  as  distinguished  from 
substance  abuse  require  any  form  of  specialty 
care;  and  (5)  it  is  based  on  data  that  are  six  years 
old.18  Adjusting  ABAM's  estimate  to  address 
these  gaps  could  increase  substantially  the 
number  of  addiction  medicine  specialists 
required  to  provide  needed  care. 

Likewise,  due  to  the  limitations  of  the  AMA 
survey  and  the  absence  of  other  data,  it  is 
impossible  to  know  how  many  of  the  1,137 
physicians  who  are  board  certified  in  addiction 
psychiatry  as  of  201 1 19  currently  are  practicing 
in  that  subspecialty  or  how  much  overlap  there 
is  with  the  number  of  physicians  certified  in 
addiction  medicine. 

Licensing  and  Credentialing 
Requirements  for  Individuals  who 
Provide  Addiction  Treatment5 

To  help  assure  adherence  to  minimum  standards 
in  the  delivery  of  medical  care,  the  licensing  and 
credentialing  requirements  of  individuals  who 
may  provide  such  care  are  clearly  delineated  and 
regulated.  For  physicians,  these  include 
extensive  graduate-level  classroom-based  and 
clinically-supervised  training,  a  focus  on 


s  The  information  provided  in  this  section  is  based  on 
an  extensive  review  of  publicly  available  documents 
conducted  by  CASA  Columbia  in  2010.  This 
entailed  online  reviews  and  updates  (using  the 
Internet  and  the  Lexis/Nexis  database)  of  publicly- 
available  federal  and  state  laws  and  regulations  (in  all 
50  states  and  the  District  of  Columbia)  and  of 
professional  association  Web  sites.  CASA 
Columbia's  analysis  examined  the  minimum 
licensing  and  certification  requirements  to  practice  in 
each  profession  in  the  50  states  and  the  District  of 
Columbia,  and  optional  certifications.  The  analysis 
sought  to  develop  a  summary  overview  of  the 
regulatory  landscape.  However,  because  licensing 
and  certification  requirements  are  found  in  a  wide 
variety  of  laws  and  regulations  and  can  change  on  a 
state  by  state  basis,  and  may  have  changed  in  certain 
states  since  the  time  of  the  review,  findings  from  this 
review  cannot  be  guaranteed  to  be  complete  and 
current.  Unless  cited  to  another  source,  the  findings 
presented  regarding  licensing  and  certification 
requirements  are  derived  from  this  review.  See 
Appendix  A  for  a  description  of  the  methodology. 


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standards  of  medical  practice   and  the  adoption 
of  evidence-based  practices  for  those  who  wish 
to  become  board  certified.21  In  contrast,  there 
are  no  clearly  delineated,  consistent  and 
regulated  national  standards  that  stipulate  who 
may  provide  addiction  treatment  in  the  United 
States;  instead,  standards  vary  by  payer  and  by 
state. 

In  2010,  CASA  Columbia  examined  the 
addiction-related  licensing  and  certification 
requirements  of  individuals  who  most  typically 
are  the  providers  of  addiction  treatment  and 
related  services  in  the  United  States.  These 
include  medical  professionals  such  as 
physicians,  physician  assistants,  nurses  and 
nurse  practitioners;  mental  health  professionals 
such  as  psychologists,  social  workers  and 
counselors/therapists;  acupuncturists;  and 
addiction  counselors.  Licensure  is  a  mandatory 
process  required  by  state  law;  licensing 
standards  are  designed  to  ensure  minimum 
competency  required  to  practice  one's 
profession  and  protect  public  health,  safety  and 
welfare.  Certification  is  a  voluntary  process 
administered  by  non-governmental 
organizations,  typically  professional 
associations.22  Certification  demonstrates 
additional  expertise  within  a  specific  area  of 
one's  profession  (i.e.,  a  specialty).23 

Of  all  these  groups,  addiction  counselors  provide 
the  majority  of  addiction  treatment  in  the  U.S.24 
Indeed  the  only  category  of  providers 
specifically  required  to  be  licensed  to  provide 
addiction  treatment  in  most  states  is  addiction 
counselors.  Yet  the  requirements  in  some  states 
for  becoming  an  addiction  counselor  include 
only  a  high  school  diploma  and  some  practical 
training-typically  involving  a  focus  on  the  12- 
step  model.25  Training  approximates  an 
apprenticeship  model  which  may  fail  to  promote 
systematic  adoption  of  evidence-based 
practices.26  Historically,  personal  experience 
with  addiction  (i.e.,  being  "in  recovery")  was  the 
primary  qualification  necessary  to  become  an 
addiction  counselor.27 

Unlike  providers  of  medical  care  who  are  trained 
in  evidence-based  medical  practices,  few  among 
the  broad  range  of  providers  who  may  treat 


patients  with  addiction  are  trained  in  or 
knowledgeable  about  evidence-based  practices 
in  addiction  prevention  and  treatment.28  While 
medical  professionals  and  some  mental  health 
professionals  may  have  the  training  and  skills 
needed  to  implement  research-based  treatments- 
-and  regularly  come  into  contact  with  patients  in 
the  target  population  of  risky  substance  users 
and  those  with  addiction—most  are  unprepared 
to  address  these  conditions.  And  while 
addiction  counselors,  who  constitute  the  largest 
proportion  of  the  workforce  in  specialty 
treatment  facilities, 29  specifically  address 
addiction,  most  lack  an  education  grounded  in 
the  science  of  addiction  and  are  not  equipped  to 
deliver  evidence-based  treatments  including 
appropriate  medical  care  and  treatment  of  co- 
occurring  health  conditions.30 

Compounding  this  problem  is  that  the  diversity 
in  education  and  training  among  the  different 
types  of  individuals  providing  addiction 
treatment  results  in  inconsistent  treatment 
approaches  and  care  for  patients  with 
addiction.31 

Medical  Professionals 

Medical  professionals  have  been  regulated  at  the 
state  level  since  Colonial  times.32  Rooted  in 
their  police  powers,  states  have  the  authority  to 
prohibit  the  performance  of  ineffective  and 
dangerous  treatments,  to  license  professionals 
and  to  define  their  scope  of  practice.33  For 
specific  licensing  standards,  states  largely  defer 
to  professional  boards  and  national  organizations 
that  accredit  education  programs.  Medical 
professionals  must  complete  an  accredited 
professional  education  program  and  pass  a 
national  licensing  exam  to  become  licensed  by 
the  state  in  which  they  practice  their  profession. 
State  licensing  requirements  may  include 
minimum  education,  training  or  skills 
demonstrated  by  earning  a  specified  degree; 
time  spent  in  clinical  training  requirements;  and 
passing  a  licensing  exam. 

Because  risky  use  of  addictive  substances  is  a 
public  health  issue  and  addiction  is  a  medical 
condition,  medical  professionals-particularly 
physicians-should  be  on  the  front  lines  in 


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treating  patients  with  these  conditions,  working 
with  a  team  of  other  qualified  health 
professionals.  However,  separate  courses  in 
addiction  medicine  rarely  are  taught  in  medical 
school34  and  there  are  no  addiction  medicine 
residencies  among  the  9,034  accredited  U.S. 
residency  programs  currently  training  1 16,404 
residents.35  Physicians,  therefore,  lack  the  basic 
education  and  training  in  addiction  medicine  that 
is  needed  to  understand  the  science  of  addiction, 
translate  research  evidence  into  practice,  screen 
for  risky  use,  diagnose  and  provide  treatment  for 
addiction  and  the  broad  range  of  co-occurring 
health  problems,  or  refer  patients  to  other 
specialists  as  needed.36 

Physicians.  To  become  a  physician,  an 
individual  must  earn  a  bachelor's  degree, 
complete  four  years  of  medical  school  to  earn  an 
M.D.  (allopathic  physician)  or  a  D.O. 
(osteopathic  physician)  and  complete  an 
additional  three  to  seven  years  of  post-graduate 
training  in  a  medical  residency  training  program 
(also  called  graduate  medical  education).37  To 
become  licensed  to  practice  medicine, 
physicians  must  pass  a  three-step  licensing 
exam;  allopathic  candidates  take  the  United 
States  Medical  Licensing  Exam  (USMLE).38 
The  USMLE  includes  addiction  as  a  possible 
subtopic  in  each  step.* 39  Those  who  choose  to 
practice  osteopathic  medicine  must  take  the 
Comprehensive  Osteopathic  Medical  Licensing 
Examination  (COMLEX)  administered  by  the 
National  Board  of  Osteopathic  Medical 
Examiners  (NBOME).40  Dimension  1  of  the 
COMLEX  exam  is  devoted  to  "Patient 
Presentation"  where  addiction  is  listed  as  a 
subtopic'  41  These  requirements  are  set  by 
national  accreditation  organizations  (that 
accredit  schools  and  residency  programs)  and 
professional  boards  (that  provide  education  and 
licensing  standards)  to  which  states  defer  when 
they  require  professional  licensing.42 


Within  the  content  areas  "Central  and  Peripheral 
Nervous  Systems:  Abnormal  Processes"  in  Step  1  of 
the  exam,  "Mental  Disorders"  in  Step  2  and 
"Behavioral/Emotional  Disorders"  in  Step  3. 
f  Within  the  content  areas  "Population  Health 
Concepts:  Disease  Detection  and  Monitoring"  and 
"Cognition,  Behavior,  Sensory  and  Central  Nervous 
Systems,  Substance  Abuse  and  Pain." 


Although  physicians  in  the  United  States  have 
extensive  competency  requirements  regarding 
most  illnesses,  their  level  of  required 
competency  in  addiction  medicine  is  minimal 
given  the  prevalence  of  risky  substance  use  and 
addiction  in  most  patient  populations.43  No 
reliable  national  data  exist  on  the  proportion  of 
medical  school  curricula  devoted  to  the  topic  of 
addiction.  A  national  survey  of  residency 
training  program  directors  in  seven  medical 
specialties  revealed  that  56.3  percent  of  the 
programs  report  having  required  curriculum 
content  in  preventing  and  treating  addiction,  but 
that  the  median  number  of  curricular  hours  of 
training  ranges  from  three  (emergency  medicine 
and  obstetrics/gynecology)  to  12  (family 
medicine).44  While  most  allopathic  medical 
schools  do  include  some  addiction  content  in 
required  coursework,45  research  suggests  that  the 
average  school  requires  few  hours  of  its  four- 
year  curriculum  to  be  devoted  to  the  topic.46 

Physicians  may  choose  to  become  board 
certified  in  a  medical  specialty,  which 
demonstrates  that  they  have  the  knowledge, 
skills  and  experience  to  treat  patients  within  that 
specialty.47  The  American  Board  of  Medical 
Specialties  (ABMS)  has  adopted  a  Maintenance 
of  Certification  (MOC)  program  for  all 
specialties  in  which  physicians  must  stay  abreast 
of  the  latest  advances  in  their  specialty  and 
demonstrate  use  of  best  practices.48 

CASA  Columbia  reviewed  the  board 
certification  exam  requirements  of  the  six 
medical  specialties  that  interact  most  often  and 
regularly  with  patients  who  engage  in  risky 
substance  use  or  have  addiction  to  determine 
their  addiction-related  content: 


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•  Internal  Medicine- two  percent  of  the 
general  board  exam.49  In  addition, 
substance  use/addiction  is  listed  as  possible 
subtopics  in  the  geriatric  medicine* 50  and 
infectious  disease51  subspecialty  exams; 
however,  the  exact  proportions  are  not 
specified. 

•  Pediatrics- 1.5  percent  of  the  general 
exam,52  five  percent  of  the  adolescent 
medicine  exam53  and  two  percent  of  the 
developmental-behavioral  pediatrics 
subspecialty  exam.54  Substance-related 
topics  also  are  listed  in  the  pediatric 
emergency  medicine,  child  abuse  pediatrics, 
and  neonatal-perinatal  medicine 
subspecialty  exams;  however,  the  exact 
proportion  is  not  specified.55 

•  Family  Medicine-no  specification  in  the 
general  board  exam,56  but  the  pharmacology 
of  and  testing  for  the  use  of  addictive 
substances  is  included  as  a  possible  subtopic 
in  the  optional  sports  medicine  subspecialty 
certification  exam.57 

•  Psychiatry— included  as  subtopics  in  the 
general  board  exam,  but  the  proportion  of 
the  total  content  is  not  specified.58  Also 
one-half  percent  of  the  forensic  psychiatry 
and  six  percent  of  the  psychosomatic 
medicine  subspecialty  exams  are  devoted  to 
substance  use/addiction.59  Substance 
use/addiction  also  is  listed  as  a  subtopic  in 


Subspecialty  certifications  in  the  same  area  may  be 
offered  by  more  than  one  medical  board.  For 
example,  the  geriatric  medicine  subspecialty 
certification  administered  by  the  American  Board  of 
Internal  Medicine  also  can  be  obtained  by  physicians 
specializing  in  family  medicine;  the  adolescent 
medicine  certification  administered  by  the  American 
Board  of  Pediatrics  also  can  be  obtained  by 
physicians  specializing  in  internal  medicine  and 
family  medicine;  the  pediatric  emergency  medicine 
exam  administered  by  the  American  Board  of 
Pediatrics  also  can  be  obtained  by  physicians 
specializing  in  emergency  medicine;  and  the  sports 
medicine  subspecialty  certification  administered  by 
the  American  Board  of  Family  Medicine  also  can  be 
obtained  by  physicians  specializing  in  internal 
medicine,  pediatrics  and  emergency  medicine. 


the  child  and  adolescent  psychiatry,  geriatric 
psychiatry  and  pain  medicine  subspecialty 
exams.60 

•  Emergency  Medicine— included  as  a  subtopic 
in  the  qualifying  examination,  although  the 
exact  proportion  and  content  are 
unspecified.61 

•  Obstetrics/Gynecology— included  in  a 
subtopic  of  the  general  written  board 
certification  exam,  although  the  exact 
proportion  is  unspecified.  Substance 
use/addiction  assessment  and  counseling  are 
listed  as  one  of  40  patient  cases  that  may  be 
covered  in  the  oral  exam.62  The 
subspecialty  of  maternal- fetal  medicine 
explicitly  lists  substance  use/addiction  as  a 
competency  for  the  certification  exam,  but 
the  exact  proportion  and  content  are 
unspecified.63 

There  are  two  areas  of  specialty  medical  practice 
in  addiction:  addiction  medicine  and  addiction 
psychiatry. 

Addiction  Medicine.  The  American  Board  of 
Addiction  Medicine  (ABAM)  offers  a  voluntary 
certification  in  addiction  medicine  to  physicians 
across  a  range  of  medical  specialties.64  The  role 
of  the  addiction  medicine  physician,  as  a 
member  of  an  interdisciplinary  team  of  health 
professionals,  includes  examining  patients  to 
establish  the  presence  or  absence  of  a  diagnosis 
of  addiction;  assessing  associated  health 
conditions  that  are  brought  on  or  exacerbated  by 
the  use  of  addictive  substances;  participating  in 
the  development  and  management  of  an 
integrated  treatment  plan;  prescribing  and 
monitoring  patients'  use  of  addiction  treatment 
medications  and  therapies;  providing  direct 
treatment  and  disease  management  for 
individuals  with  severe  cases  of  addiction  and 
providing  consultation  to  other  primary  and 
specialty  care  providers.65  To  become  certified 
in  addiction  medicine,  applicants  must  meet 
specific  educational  and  clinical  requirements 
including: 


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•  Graduating  from  a  medical  school  in  the 
U.S.  or  Canada  approved  by  the  Liaison 
Committee  on  Medical  Education  (LCME) 
or  the  Committee  on  Accreditation  of 
Canadian  Medical  Schools  (CACMS)  or 
from  a  school  of  osteopathic  medicine 
approved  by  the  American  Osteopathic 
Association  (AO A);*  66 

•  Being  an  ABMS  board-certified  physician 
or  having  completed  a  residency  training 
program'  in  any  medical  specialty,  plus  50 
hours  of  addiction  medicine  educational 
course  work  (continuing  medical 
education/CME);67 

•  Completing  at  least  1 ,920  hours  in  teaching, 
research,  administration  and  clinical  care 
related  to  prevention  and  treatment  for 
individuals  who  are  at  risk  for  or  have 
addiction,  or  completing  a  one-year  ABAM 
Foundation-accredited  addiction  medicine 
residency  training  program;68 

•  Passing  a  five  and  a  half-hour  computer- 
based  examination;69  and 

•  Holding  a  valid  and  unrestricted  license  to 
practice  medicine  in  the  United  States,  its 
territories  or  Canada.70 

Physicians  must  maintain  their  certification 
through  ABAM's  Maintenance  of  Certification 
(MOC)  program  of  continuing  education  and 
periodic  examinations.71 


If  applicants  are  graduates  of  medical  schools 
outside  the  U.S.  or  Canada,  they  must  have  a 
currently  valid  standard  certificate  from  the 
Educational  Commission  for  Foreign  Medical 
Graduates  (ECFMG)  or  have  passed  the  Medical 
Council  of  Canada  Evaluating  Examination 
(MCCEE). 

1  Residency  programs  must  be  accredited  by  one  of 
the  following:  the  Accreditation  Council  for  Graduate 
Medical  Education  (ACGME),  the  Royal  College  of 
Physicians  and  Surgeons  of  Canada,  the  Professional 
Corporation  of  Physicians  of  Quebec  or  residency 
programs  accepted  by  any  member  board  of  the 
American  Board  of  Medical  Specialties  (ABMS)  as 
qualifying  to  sit  for  that  member  board's  certification 
examination. 


Though  not  yet  a  member  board  of  the  ABMS, 
ABAM  is  working  to  gain  recognition  of 
addiction  medicine  as  a  medical  specialty.72 

Addiction  Psychiatry.  The  American  Board  of 
Psychiatry  and  Neurology,  Inc.  offers  optional 
certification  in  addiction  psychiatry.  Addiction 
psychiatrists  are  trained  to  identify  and  treat  co- 
occurring  addiction  and  psychiatric  disorders  in 
individuals  seeking  treatment  for  either 
condition,  and  in  therapies  tailored  to  specific 
subgroups  of  patients  with  addiction.73 
Addiction  psychiatry  is  recognized  by  the 
ABMS.74  Candidates  for  certification  are  board- 
certified  psychiatrists  who  have  completed  a 
one-year  fellowship  in  addiction  psychiatry.75 

Physician  Assistants.  Physician  assistants  are 
licensed  to  assist  physicians  in  the  practice  of 
medicine,  enabling  them  to  perform  many  of  the 
same  duties  that  physicians  perform,  including 
medical  assessments  and  prescribing 
medication.76  The  precise  scope  of  their  practice 
varies  according  to  the  regulations  of  each  state. 

All  states  license  and  regulate  physician 
assistants  and  require  graduation  from  an 
accredited  physician  assistant's  program  and 
passing  of  the  Physician  Assistant  National 
Certifying  Examination  (PANCE)  administered 
by  the  National  Commission  on  Certification  of 
Physician  Assistants  (NCCPA).77  States  defer  to 
the  national  accreditation  agency  and 
professional  board  for  content  requirements.  All 
physician  assistants  must  complete  two  years  of 
college  course  work  in  basic  and  behavioral 
sciences  and  earn  a  degree  from  a  program1 
accredited  by  the  Accreditation  Review 
Commission  on  Education  for  the  Physician 
Assistant  (ARC-PA).78  Most  programs  (more 
than  80  percent)  award  a  master's  degree.79 


1  Physician  assistant  programs  are  approximately  27 
months  long. 


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The  ARC-PA  requires  physician  assistant 
programs  to  provide  some  instruction  in  the 
"detection  and  treatment  of  substance  abuse" 
although  the  nature  and  extent  of  this  instruction 
is  not  specified.80  The  PANCE  exam  may 
include  addiction  in  its  psychiatry^ehavioral 
exam  category.* 81 

As  of  2010,  all  states  permit  physicians  to 
delegate  prescription  privileges  to  physician 
assistants82  and  all  states  except  Florida  and 
Kentucky  allow  physician  assistants  to  prescribe 
certain  controlled  substances  under  medical 
supervision.83  Yet  physician  assistants,  like 
other  medical  professionals,  receive  little 
training  in  addiction  in  spite  of  the  fact  that  they 
can  prescribe  controlled  substances. * 

Nurses.  States  offer  several  categories  of 
licensing  in  the  nursing  profession,  each  with 
different  standards,  practice  limitations  and 
supervision  requirements.  As  they  do  for 
physicians,  states  defer  to  national  accreditation 
agencies  and  professional  boards  for  specific 
licensing  standards  for  nurses.  To  be  a  licensed 
registered  nurse  (RN),  one  must  graduate  from 
an  accredited  nursing  program  which  includes 
earning  either  a  bachelor's  of  science  degree  in 
nursing  (BSN),  an  associate's  degree  in  nursing 
(ADN)  or  completing  a  diploma  program 
(administered  in  hospitals).84  Graduates  from 
each  program  are  eligible  to  take  the  National 
Council  Licensure  Exam  (NCLEX), 
administered  by  the  National  Council  of  State 


*  Each  question  addresses  one  organ  system  along 
with  one  of  seven  practice  areas:  history  taking  and 
physical  examinations,  using  laboratory  and 
diagnostic  studies,  formulating  a  most  likely 
diagnosis,  health  maintenance,  clinical  interventions, 
pharmaceutical  therapeutics  and  applying  basic 
science  concepts. 

t  A  few  states  require  physician  assistants  to  be 
trained  in  addiction.  Physician  assistants  in  CA  who 
wish  to  prescribe  controlled  substances  without 
advanced  approval  from  a  supervising  physician  are 
required  to  take  a  controlled  substance  education 
course  which  includes  assessment  of  risky  substance 
use  and  addiction.  In  OK,  all  physician  assistants 
must  complete  one  hour  of  continuing  education  per 
year  on  the  topic  of  addiction. 


Boards  of  Nursing,  and  they  must  pass  this  exam 
to  become  a  licensed  RN.85 

Even  though  most  nurses  interact  regularly  with 
individuals  who  are  risky  users  or  who  have 
addiction,86  CASA  Columbia's  review  found 
that  in  all  but  several  states1  addiction-related 
education  is  not  required  explicitly  in  curriculum 
guidelines  for  state  nursing  programs.  Other 
research  found  that  many  nursing  education 
programs  do  not  teach  current  information 
related  to  addiction.87  The  National  League  for 
Nursing  Accrediting  Commission  and  the 
Commission  on  Collegiate  Nursing  Education, 
the  two  main  accrediting  agencies  for  nursing 
schools,  do  not  require  addiction  to  be  part  of 
nursing  curricula.88  Addiction,  including  the 
topic  of  smoking  cessation,  may  be  included  as 
topics  on  the  licensing  exams  for  registered  and 
practical/vocational  nurses.89  The  American 
Academy  of  Nursing  recently  published  new 
core  clinical  competencies  in  mental  health  that 
should  be  expected  of  all  RNs.  They  include 
knowledge  about  the  disease  of  addiction, 
addiction  treatment,  the  pharmacology  of 
commonly-misused  illicit  and  prescription 
drugs,  comprehensive  screening,  motivational 
interviewing,  patient  outcome  evaluation, 
comprehension  of  research  literature  and  the 
adoption  of  evidence-based  practices.90 

In  most  states,  advanced  practice  nurses  (APN) 
must  earn  a  master's  degree  and  are  authorized 
to  prescribe  both  non-controlled  and  controlled 
substances;91  however,  few  states  explicitly 
include  addiction-related  content  in  their  training 
requirements. 

The  International  Nurses  Society  on  Addictions 
(IntNSA)  offers  an  optional  certificate  in 
addiction  nursing;  to  qualify,  candidates  must 


1  In  CA,  RNs  must  complete  studies  in  alcohol  and 
other  drug  addiction;  however,  the  exact  amount  is 
not  specified.  In  IL,  programs  in  practical  nursing 
must  include  a  course  in  pharmacology  which  must 
include  topics  on  substance  use  and  addiction.  IN 
and  RI  require  some  addiction  education  and  NJ 
requires  six  contact  hours  in  pharmacology  related  to 
controlled  substances  including  the  prevention  and 
management  of  addiction  involving  these  substances. 


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have  200  hours  (one  year)  of  addiction-specific 
experience  as  an  RN  and  pass  an  examination.92 

Mental  Health  Professionals 

As  is  true  of  medical  professionals,  the  licensing 
of  mental  health  professionals  is  regulated  by  the 
states,  which  defer  to  national  accreditation 
organizations  and  professional  boards. 

Psychologists.  Licensed  clinical  and  counseling 
psychologists  must  obtain  a  doctorate  degree 
from  a  PhD  or  PsyD  program  at  an  accredited  or 
government-chartered  institution  acceptable  to 
the  American  Psychological  Association  (APA) 
licensing  board.93  They  also  must  pass  a 
national  licensing  examination,  the  Examination 
for  Professional  Practice  in  Psychology, 
administered  by  the  Association  of  State  and 
Provincial  Psychology  Boards.94  Vermont  and 
West  Virginia  offer  a  psychologist  license  at  the 
master's  level* 

In  the  course  of  their  practice—whether  in  the 
mental  health  care  system,  the  general  health 
care  system,  the  correctional  system,  schools 
and  universities  or  specialty  addiction  treatment 
programs— clinical  and  counseling  psychologists 
encounter  many  patients  who  engage  in  risky 
substance  use  or  have  addiction.  Psychologists 
often  hold  administrative  and  supervisory 
positions  in  specialty  addiction  treatment 
programs  and  other  health  and  social  welfare 
systems  with  large  numbers  of  substance- 
involved  individuals.95  Yet  CASA  Columbia's 
review  found  that  in  most  states,  addiction  is  not 
a  required  element  of  psychologists'  training. ' 

In  the  national  licensing  exam  for 
psychologists,  addiction-related  content  may 
appear  as  part  of  the  required  knowledge  base  in 


A  number  of  states  also  license  temporary  or 
renewable  psychological  associate  licenses  for 
master's  level  supervised  practitioners. 

*  CA  requires  all  licensed  psychologists  to  have  some 
level  of  addiction-related  education;  applicants  must 
complete  at  least  a  semester  course  in  addiction 
detection  and  treatment. 

*  The  Examination  for  Professional  Practice  in 
Psychology,  administered  by  the  Association  of  State 
and  Provincial  Psychology  Boards  (ASPPB). 


several  content  areas,  including  "biological 
bases  of  behavior"  and  "assessment  and 
diagnosis. "§  96 

The  APA  had  offered  an  optional  certificate 
related  to  substance  use  and  addiction  which, 
although  recognized  by  some  state  agencies, 
was  not  required  for  a  psychologist  to  treat 
patients  with  addiction;  the  only  requirement  for 
this  certification  was  experience  in  treating 
addiction  as  a  licensed  psychologist  for  at  least 
one  year.97  As  of  January  1,  201 1,  the  APA 
Practice  Organization  (APAPO)  discontinued 
accepting  new  applications  for  the  Certificate  of 
Proficiency  in  the  Treatment  of  Alcohol  and 
Other  Psychoactive  Substance  Use  Disorders  but 
continues  to  support  the  credential  for 
previously-certified  psychologists  who  maintain 
their  certification  by  engaging  in  appropriate 
continuing  education.  The  decision  to 
discontinue  the  certification  program  for  new 
applicants  was  based  in  part  on  insufficient 
interest  in  obtaining  the  credential  by  licensed 

98 

psychologists. 

Mental  Health  Counselors/Therapists.  All 

states  license  mental  health  counselors99  and, 
with  the  exception  of  the  "professional 
counselor"  license  in  Illinois, ft  all  states  require 
at  least  a  master's  degree  in  counseling  or  a 
related  field. 

The  National  Board  for  Certified  Counselors 
(NBCC)  offers  certification  to  become  a 
National  Certified  Counselor  (NCC);  in 
addition,  three  optional  national  specialty 
certifications  are  offered  on  the  graduate  level  to 
become  a  school  counselor,  clinical  mental 


§  Although  these  content  areas  constitute  40  percent 
of  the  test,  the  exact  proportion  of  substance 
use/addiction  content  is  not  specified. 

There  are  a  number  of  different  ways  that  state 
agencies  have  recognized  the  certificate.  Most  states 
use  it  as  one  way  for  psychologists  to  be  listed  as 
registered  addiction  treatment  providers  or  as  one 
way  to  qualify  them  as  clinical  supervisors.  The 
significance  of  these  categories  depends  on  the  state's 
regulations. 

^  IL  requires  only  a  bachelor's  degree.  IL  also  has  a 
"clinical  professional  counselor"  license  which 
requires  a  master's  degree. 


-183- 


health  counselor  and  master  addictions 
counselor.*  100  The  National  Counselor 
Examination  for  Licensure  and  Certification 
(NCE),  administered  by  NBCC,  is  required  for 
those  seeking  certification.  The  NCE  exam  does 
not  appear  to  contain  substance  use/addiction- 
related  content;101  however,  the  specialty 
certification  exam  administered  by  the  NBCC 
for  the  master  addictions  counselor  exam 
focuses  on  addiction.102  The  master  addictions 
counselor  certification  requires  (1)  a  minimum 
of  12  semester  hours  of  graduate  coursework  in 
addiction  content  or  500  continuing  education 
hours  in  addiction  content;  (2)  three  years  of 
supervised  experience  as  an  addiction  counselor 
at  a  minimum  of  20  hours  per  week  (two  of  the 
three  years  must  have  been  completed  after 
obtaining  the  master's  degree  in  counseling); 
and  (3)  a  passing  score  on  the  examination  for 
master  addictions  counselor.103  National 
certification  is  voluntary;  however,  in  some 
states,  counselors  are  exempt  from  taking  a  state 
certification  exam  if  they  pass  the  national 

104 

exam. 

Professional  counselors  are  trained  to  provide 
treatment  for  mental,  emotional  and  behavioral 
disorders  and  tend  to  encounter  in  their  practice 
individuals  who  engage  in  risky  substance  use  or 
have  addiction.105  Although  risky  substance  use 
and  addiction  may  be  addressed  under  broad 
course  content  areas,  CASA  Columbia's  review 
found  few  explicit  state  licensing  requirements 
that  mandate  a  specific  number  of  addiction- 
related  education  hours  in  their  curriculum 
guidelines.1 

The  Council  for  Accreditation  of  Counseling 
and  Related  Educational  Programs  (CACREP), 
which  accredits  master's  programs  in  numerous 
counseling  specialties,  requires  all  programs  to 
provide  students  with  an  understanding  of 
"theories  and  etiology  of  addictions  and 
addictive  behaviors,  including  strategies  for 


The  NCC  is  a  pre-  or  co-requisite  for  the  specialty 
credentials. 

1  More  frequently,  states  mention  substance  use  and 
addiction  as  topics  that  may  be  addressed  under 
content  areas  such  as  human  growth  and  development 
or  that  may  be  taken  as  electives  or  continuing 
education  courses. 


prevention,  intervention  and  treatment."  The 
CACREP  specifically  includes  additional 
substance-related  content  in  the  curricular 
requirements  for  clinical  mental  health 
counseling;  marriage,  couple  and  family 
counseling;  school  counseling;  and  student 
affairs  and  college  counseling  programs.106 
Surveys  of  these  programs  reveal,  however,  that 
the  majority  of  CACREP-accredited  master's 
programs  in  counseling  offer  elective  courses 
but  do  not  require  substance  use/addiction- 
related  course  work.  When  asked  to  identify 
which  courses  teach  addiction-related  content, 
CACREP  programs  typically  cite  supervised 
clinical  settings  (practicums  and  internships), 
where  students  encounter  patients  who  engage  in 
risky  substance  use  or  have  addiction,  rather 
than  classroom-based  courses.  Most  counseling 
degree  programs  do  not  provide  any  addiction 
education  prior  to  the  clinical  experience.107 

Marriage  and  Family  Therapists.  Marriage  and 
family  therapists  either  must  have  a  master's 
degree,  a  doctoral  degree  or  three  to  four  years 
of  post-graduate  clinical  training  for  licensure.108 
According  to  CASA  Columbia's  review,  few 
states  have  explicit  addiction-related  education 
requirements  (such  as  minimum  number  of 
hours  of  addiction  content);  most  states  that 
mention  addiction  include  it  as  an  optional  or 
suggested  topic  or  as  a  topic  eligible  for 
continuing  education  credit.  The  national 
licensing  exam  in  Marital  and  Family  Therapy  is 
administered  by  the  Association  of  Marital  and 
Family  Therapy  Regulatory  Boards  (AMFTRB). 
In  drafting  the  Examination  in  Marital  and 
Family  Therapy,  the  Examination  Advisory 
Committee  draws  from  a  list  of  the  56 
knowledge  areas  required  for  entry- level 
practice  in  marital  and  family  therapy,  which 
includes  two  areas  related  to  substance  use  and 
addiction.1 109 

Social  Workers.  Some  social  workers  function 
as  mental  health  professionals,  providing 
counseling  services.  Social  workers  must  earn, 


1  The  substance-related  areas  in  the  AMFTRB  are 
"effect  of  substance  abuse  and  dependence  on 
individual  and  family  functioning"  and  "addiction 
treatment  modalities." 


-184- 


at  a  minimum,  a  bachelor's  degree  in  social  work 
(BSW);  however,  a  master's  degree  in  social 
work  (MSW)  often  is  required  for  positions  in 
health  care  settings  or  to  provide  clinical 
services.110 

The  Association  of  Social  Work  Boards 
(ASWB),  which  regulates  the  profession, 
administers  four  separate  examinations:  the 
bachelor's  exam,  master's  exam,  advanced 
generalist  exam  and  clinical  exam.   Each  state 
determines  the  examination  required  for 
licensure. 

More  than  25  percent  of  patients  whom  social 
workers  come  into  contact  with  either  have  a 
primary  or  secondary  diagnosis  of  addiction.111 
While  addiction-related  content  is  mentioned 
explicitly  as  a  topic  area  that  may  be  included  in 
the  bachelor-  and  clinical-level  licensing 
examinations,112  CASA  Columbia's  review 
identified  just  two  states— California  and  Alaska- 
-that  require  social  workers  to  complete 
coursework  in  addiction. '  113 

The  National  Association  of  Social  Workers 
offers  an  optional  Certified  Clinical  Alcohol, 
Tobacco,  and  Other  Drugs  Social  Worker  (C- 
CATODSW)  certification  for  master's  level 
social  workers  with  180  hours  of  addiction- 
related  education  and  two  years  of  paid, 
supervised  post-graduate  work  experience  in 
both  clinical  social  work  and  addiction 
counseling.  *  114 


In  general,  the  bachelor's  exam  is  designed  for 
those  with  a  BSW  and  no  post-degree  experience;  the 
master's  exam  is  for  those  with  an  MSW  and  no  post- 
degree  experience;  the  advanced  generalist  exam  is 
for  those  with  an  MSW  and  at  least  two  years  of  post- 
degree  experience  in  non-clinical  settings;  and  the 
clinical  exam  is  for  those  with  an  MSW  and  at  least 
two  years  of  post-degree  experience  in  direct  clinical 
practice  settings. 

*  In  CA,  the  applicant  must  obtain  at  least  15  hours  of 
addiction-related  training.  In  AK,  licensed  social 
workers  must  complete  45  hours  of  continuing 
education,  including  six  hours  of  addiction-related 
education  during  their  bi-annual  license  renewal 
cycle. 

*  Nationwide  data  on  the  number  of  practicing  social 
workers  with  this  certification  are  not  available. 


Acupuncturists 

Acupuncture  sometimes  is  used  as  an 
alternative/complementary  treatment  for 
addiction.  Estimates  are  that  several  hundred 
addiction  treatment  clinics  in  the  U.S.  and 
Europe  offer  auricular  acupuncture,  a  procedure 
that  targets  chronic  diseases,  including  addiction 
through  needle  therapy  of  the  ear  (typically  used 
to  treat  cocaine  addiction).115  Despite  its 
widespread  use,  there  is  very  little  research 
supporting  the  efficacy  of  auricular  acupuncture 
for  the  treatment  of  addiction.116 

CASA  Columbia's  review  found  that  most  states 
require  individuals  who  practice  acupuncture  to 
be  licensed.  Licensing  requirements  include 
earning  a  degree  from  an  accredited  acupuncture 
school  and,  except  in  four  states,  professional 
certification  or  examination  by  the  National 
Certification  Commission  for  Acupuncture  and 
Oriental  Medicine  (NCCAOM).  In  Alabama 
and  North  Dakota,  which  do  not  have  licensure 
requirements  for  acupuncturists,  only 
physicians,  osteopaths  or  chiropractors  may 
practice  acupuncture  as  permitted  by  their  scope 
of  practice  or  via  specialty  certification.5  117 

CASA  Columbia's  review  identified  several 
states  that  require  specialized  training  and 
certification  to  practice  auricular  acupuncture. 
In  California,  acupuncture  training  programs  are 
required  to  teach  both  auricular  acupuncture  and 
principles  of  public  health,  including  treatment 
of  addiction.118  Acupuncturists  certified  through 
NCCAOM  for  Acupuncture  and  Oriental 
Medicine  are  not  required  explicitly  to  have 
addiction-related  training,  although  substance- 
related  knowledge  is  in  the  exam  content  for  the 
"diplomate  in  acupuncture"  certification.119  The 
National  Acupuncture  Detoxification 
Association  (NAD A) 120  certifies  Acupuncture 


s  In  KS,  acupuncturists  may  practice  under  the 
supervision  of  a  medical  doctor,  osteopath  or 
chiropractor.  In  OK,  medical  doctors  may  practice 
acupuncture.  In  SD,  chiropractors  may  practice 
acupuncture.  WY  has  no  laws  or  regulations 
permitting  or  prohibiting  acupuncture  practice. 


-185- 


Detoxification  Specialists  (ADS)  and  has  its 
own  set  of  training  guidelines.*  121 

Addiction  Counselors 

Addiction  counselors,  also  known  as  Substance 
Abuse  Counselors  (SACs),  Credentialed 
Alcoholism  and  Substance  Abuse  Counselors 
(CASACs)  or  Alcohol  and  Drug  Counselors 
(ADCs),  make  up  the  largest  share  of  full-time 
addiction  treatment  provider  staff  in  facilities 
providing  addiction  treatment  in  the  United 
States.122 

Addiction  counselors  can  be  licensed,  certified 
or  both.123  CASA  Columbia's  review  found  that 
37  states  require  addiction  counselors  either  to 
be  licensed  or  certified,  although  even  these 
states  may  provide  important  exemptions. ' 

The  review  also  found  that  to  become  a  licensed 
addiction  counselor  in  a  given  state,  generally 
one  must  meet  the  state's  minimum  education 
and  training  requirements  and  pass  a  designated 
exam.  There  is  no  one  national  licensing  exam 
used  to  measure  competencies.124  The  state 
education  qualifications  for  licensure  vary 
greatly/  125  According  to  CASA  Columbia's 
review,  more  than  half  of  states  that  offer 
licensing  require  a  master's  degree  for  the 


The  NADA  training  guidelines  include  30  hours  of 
didactic  classroom  training  (e.g.,  history  of  the 
profession;  the  NADA  protocol  which  defines  the 
five  points  where  needles  are  to  be  applied; 
techniques;  clean  needle;  integration  with  larger 
treatment  program;  ethics)  and  40  hours  of  hands-on 
clinical  work  (content  not  specified),  supervised  by  a 
licensed  acupuncturist. 

'  Such  as  supervised  students  engaged  in  practicum, 
licensed  health  care  professionals  (e.g.,  MDs,  RNs, 
psychologists)  working  within  their  scope  of 
profession,  religious  leaders  working  within  the 
scope  of  their  ministerial  duties,  government 
employees  working  within  the  scope  of  their 
employment,  and  short-term  services  provided  by 
non-residents  who  are  certified  in  another  state. 
*  There  are  several  tiers  of  addiction  counselors— such 
as  Certified  Alcohol  and  Drug  Abuse  Counselor 
(CADAC)  or  Substance  Abuse  Counselor  (SAC)- 
each  with  its  own  proficiency  requirements  (based  on 
education  and  experience).  The  highest  level  usually 
requires  a  master's  or  doctorate  degree. 


highest  level  of  licensure,  although  several  states 
offer  the  highest  level  of  licensure  to  individuals 
who  only  have  a  bachelor,  associate  or  high 
school  degree.  A  1998  survey  similarly  found 
that  56  percent  of  licensed  addiction  counselors 
have  at  least  a  master's  degree.126 

A  variety  of  state  boards  and  non-governmental 
organizations  are  designated  with  responsibility 
for  certifying  addiction  counselors.127  Similar  to 
the  licensure  process,  certification  recognizes 
that  addiction  counselors  have  met  what  the 
organization  deems  to  be  minimum  standards  of 
education  and  clinical  experience.128  In  some 
states  addiction  counselors  must  be  certified 
while  in  other  states  certification  is  voluntary.129 
Some  state  certification  boards  defer  to 
standards  established  by  professional 
membership  or  credentialing  organizations,  such 
as  the  International  Certification  and  Reciprocity 
Consortium  (IC&RC)  or  NAADAC,  the 
Association  for  Addiction  Professionals,5  130 
which  do  not  stipulate  a  particular  required 
degree  for  the  entry  level  certification.131 

The  IC&RC  establishes  minimum  education  and 
training  standards  for  the  credentialing  of 
addiction  counselors— each  state  certification 
board  that  is  a  member  of  the  IC&RC 
consortium  either  may  follow  the  minimum 
standards  or  impose  higher  standards.132  The 
focus  of  the  minimum  requirements  for  the 
IC&RC  Alcohol  and  Drug  Counselor  (ADC) 
certification  is  more  on  clinical  work  experience 
than  on  classroom-based  education: 
requirements  include  270  hours  of  education  in 
the  eight  domains  of  addiction  counseling,  300 
hours  of  supervised  practical  experience  in  the 
eight  domains,  6,000  hours  of  supervised 


s  The  National  Association  for  Alcoholism  and  Drug 
Abuse  Counselors  (NAADAC)  changed  its  name  in 
2001  to  NAADAC,  the  Association  for  Addiction 
Professionals  to  reflect  the  increasing  number  of 
addiction  professionals  who  address  forms  of 
addiction  involving  behaviors  other  than  substance 
use,  such  as  gambling. 

The  eight  domains  include:  clinical  evaluation; 
treatment  planning;  referral;  service  coordination; 
counseling;  client,  family  and  community  education; 
documentation;  and  professional  and  ethical 
responsibilities. 


-186- 


professional  work  experience  specific  to  the 
eight  domains  and  successful  completion  of  a 

1  33 

written  examination. 

NAADAC,  the  Association  for  Addiction 
Professionals  offers  three  levels  of  certification 
for  addiction  professionals  based  on  experience 
and  education.134  Like  the  IC&RC  requirements 
for  the  National  Certified  Addiction  Counselor, 
Level  I  (NCAC  I),  the  focus  primarily  is  on 
clinical  work  experience  rather  than  on 
classroom-based  education.  Requirements 
include:  (1)  a  current  state  certificate  or  license 
as  an  addiction  counselor;  (2)  270  contact  hours 
of  addiction  counseling  training;  (3)  three  years 
of  full-time  work  experience  or  6,000  hours  of 
supervised  experience  as  an  addiction  counselor; 
and  (4)  successful  completion  of  a  written 
examination. 

These  certification  requirements  reflect  a  great 
reliance  on  apprenticeships  as  the  training  model 
for  addiction  counselors.136 

CASA  Columbia's  state-by-state  analysis  of 
regulations  and  statutes  found  that  14  states  do 
not  require  addiction  counselors  in  all  settings  to 
be  licensed  or  certified.   Six  states  do  not 
mandate  any  degree  to  become  credentialed  as 
an  addiction  counselor;1  in  14  states,  an 
individual  may  become  licensed  or  certified  as 
an  addiction  counselor  with  the  minimum 
education  requirement  of  a  high  school  diploma 
or  a  GED;  an  associate's  degree  is  required  in  10 


In  AR,  counselors  who  are  not  licensed  or  certified 
must  register  with  the  state;  CT,  FL  and  NY  do  not 
require  supervised  staff  and  MA  does  not  require 
staff  in  licensed  facilities  to  be  licensed  or  certified; 
ID,  MS,  OR,  and  SD  require  licensing  or  certification 
of  counselors  only  in  certain  facilities  (e.g.,  licensed 
facilities  or  those  that  receive  public  funds);  HI 
insurance  law  requires  clinical  licensure  and 
certification  to  qualify  for  reimbursement;  in  MO, 
staff  who  are  not  licensed  or  certified  have  a  limited 
scope  of  practice;  in  WV,  only  counselors  in  opioid 
treatment  facilities  must  be  certified  or  licensed;  and 
AK  and  NH  do  not  appear  to  require  counselors  to  be 
licensed  or  certified. 

'  In  states  where  no  degree  is  required,  certification 
requirements  typically  include  270  hours  of 
education  in  addiction  counseling. 


states,  a  bachelor's  degree  is  required  in  six 
states  and  a  master's  degree  is  the  minimum 
requirement  in  only  one  state.* 

CASA  Columbia's  survey  of  New  York  State 
addiction  treatment  staff  providers  found  that 
35.0  percent  had  a  graduate  degree,  27.7  percent 
had  a  bachelor's  degree,  29.9  percent  had  some 
college  or  an  associate's  degree  and  6.6  percent 
had  only  a  high  school  or  GED  degree.137 

In  spite  of  the  limited  education  and  training 
requirements  and  the  apprenticeship  model  of 
training,  the  essential  practice  dimensions  of 
addiction  counseling  are  defined  as  including 
clinical  evaluation;  treatment  planning;  referral; 
service  coordination;  and  individual,  group, 
family  and  couples  counseling138— practices  that 
would  seem  to  require  far  more  extensive  and 
structured  clinical  training  than  the  field  of 
addiction  counseling  requires. 

Licensure,  Certification  and 
Accreditation  Requirements  for 
Addiction  Treatment  Programs  and 
Facilities 

Just  as  licensing  and  certification  requirements 
are  insufficient  to  assure  that  those  providing 
addiction  treatment  have  the  knowledge  and 
skills  to  do  so,  government  and  professional 
oversight  of  addiction  treatment  facilities  and 
programs  is  insufficient  to  insure  that  patients 
receive  clinically-indicated,  quality  care. 

Regulatory  oversight  of  health  care  facilities 
may  include  state  licensure,  certification^  and/or 
accreditation  by  a  national  accrediting 
organization.  Licensing  and  certification 
standards  may  include: 


1  CASA  Columbia  reviewed  the  minimum  education 
requirements  for  certification/  licensure  in  each  state. 
In  many  states,  counselors  who  meet  only  the 
minimum  education  requirements  must  be 
supervised. 

§  In  the  case  of  opioid  maintenance  therapy. 


-187- 


•  Professional  staffing  requirements  to  assure 
that  clinical  staff  are  adequately  qualified  to 
implement  evidence-based  practices; 

•  Requirements  related  to  services  to  be 
delivered;  or 

•  Requirements  that  treatment  services 
actually  help  patients  achieve  desired 
outcomes  of  improved  health  and 
functioning.139 

Like  health  care  facilities,  addiction  treatment 
programs  are  subject  to  state  licensing 
requirements;  however,  for  addiction  treatment 
programs,  these  requirements  typically  are  set  by 
state  agencies  separately  charged  with  authority 
to  oversee  addiction  services  rather  than  by  the 
agencies  responsible  for  regulating  health  care 
facilities.140  CASA  Columbia's  review  of 
licensing  and  certification  requirements  for 
addiction  treatment  facilities  and  programs ' 
found  that  the  nature  and  extent  of  these 
regulations  vary  significantly  among  states  and 
that  certain  addiction  treatment  programs  (e.g., 
many  state-run  and  religious  programs)  are 
exempt  entirely  from  state  regulation.  In 
facilities  that  are  subject  to  state  regulation,  the 
staffing  requirements  do  not  consistently 
mandate  the  involvement  of  professionals  who 
are  capable  of  providing  a  full  range  of  effective 
interventions  (including  pharmaceutical  and 
psychosocial  therapies),  services  rarely  are 
required  to  reflect  best  practices  and  quality 


Including  (1)  organizations  or  facilities  that  provide 
non-hospital  based  residential  or  outpatient  addiction 
treatment,  or  opioid  replacement  therapy  (e.g., 
methadone  maintenance  clinics)  and  (2)  hospital- 
based  inpatient  and  outpatient  addiction  treatment 
programs. 

1  This  entailed  online  reviews  and  analyses  of 
publicly  available  documents  related  to  federal  and 
state  laws  and  regulations  (in  all  50  states  and  the 
District  of  Columbia),  including  the  use  of  the 
Lexis/Nexis  database  to  supplement  information 
related  to  state  laws  and  regulations  available  on  the 
Internet.  Because  licensing  and  certification 
requirements  are  found  in  a  wide  variety  of  laws  and 
regulations  and  can  change  on  a  state  by  state  basis, 
findings  from  this  review  cannot  be  guaranteed  to  be 
complete  and  current. 


assurance  requirements  seldom  stipulate  that 
patient  outcome  data  be  collected,  analyzed  or 
made  available  to  the  public.  For  no  other 
health  condition  are  such  exemptions  from 
routine  governmental  oversight  considered 
acceptable  practice. 

State  Licensing  Requirements 

Health  care  facilities  such  as  hospitals  and 
ambulatory  care  (outpatient)  clinics  are  licensed 
by  state  departments  of  health,  whereas  the 
licensing  authority  for  addiction  treatment 
facilities  and  programs  is  distributed  across  a 
variety  of  governmental  agencies  and  the 
content  of  statutes  and  regulations  varies  greatly 
by  state.141 

Most  (81.9  percent)  addiction  treatment  facilities 
and  programs  that  voluntarily  participate  in  a 
national  survey  of  such  providers1  are  licensed 
by  the  state  agency  responsible  for  addiction 
services  (which  varies  from  state  to  state):  41.4 
percent  of  facilities  are  licensed  by  the  state 
department  of  health;  35.3  percent  by  the  state 
mental  health  department;  and  7. 1  percent  by  the 
hospital  licensing  authority.5  142 

Despite  the  abundant  evidence  that  addiction 
and  mental  health  conditions  co-occur  at  very 
high  rates  and  are  best  addressed  in  an  integrated 
manner,  in  some  states,  treatment  facilities  and 
programs  cannot  be  dually  licensed  to  provide 
both  mental  health  and  addiction  treatment 

143 

services. 


1  The  National  Survey  of  Substance  Abuse  Treatment 
Services  (N-SSATS)  of  the  Substance  Abuse  and 
Mental  Health  Services  Administration  (SAMHSA) 
is  a  national  survey  of  public  and  private  addiction 
treatment  programs  and  facilities  in  the  United  States, 
excluding  treatment  programs  in  jails  and  prisons. 
Participation  is  voluntary  and  the  survey  does  not 
represent  all  treatment  providers. 
§  These  categories  are  not  mutually  exclusive.  More 
than  half  (57.7  percent)  of  the  addiction  treatment 
facilities  that  participate  in  the  survey  are  not 
licensed  either  by  the  state  department  of  health  or 
the  hospital  agency— the  two  departments  responsible 
for  licensing  health  care  facilities. 


-188- 


A  significant  number  of  states  exempt  state 
agency-run  programs  (e.g.,  in  the  justice  and 
welfare  systems)  from  licensure.  A  national 
study  of  state-run  treatment  programs  found  that, 
excluding  programs  provided  or  operated  by  the 
state  addiction  treatment  agencies,  only  about 
one-half  of  state  agencies  that  operate  treatment 
programs  require  the  programs  they  operate  to 
meet  state  licensure  standards:144 

•  38  states  report  that  the  department  of 
corrections  operates  treatment  programs,  but 
only  1 8  of  these  require  treatment  programs 
operated  by  the  corrections  departments  to 
meet  state  licensing  standards.*  145 

•  1 3  states  report  that  their  juvenile  justice 
system  operates  treatment  programs,  with 
only  six  states  requiring  these  programs  to 
adhere  to  state  licensing  standards.146 

•  Seven  states  identify  their  departments  of 
child  and  family  services  as  operating 
treatment  programs,  with  only  four  requiring 
adherence  to  state  licensing  standards.147 

•  18  states  identified  2 1  other  government 
agencies  (e.g.,  departments  of  public 
welfare,  mental  health  and  criminal  justice- 
related  agencies  other  than  the  department  of 
corrections)  that  operate  treatment 
programs,  but  in  only  1 1  states  are  these 
programs  required  to  adhere  to  state 
licensing  standards.148 

CASA  Columbia  also  found  substantial 
inconsistencies  in  the  regulation  of  faith-based 
programs  that  offer  addiction-related  services. 
While  most  states  do  not  appear  explicitly  to 
address  faith-based  programs  in  their  laws  or 
regulations,  some  states  explicitly  exempt  such 
programs  from  regulation^ 


Federal  Regulatory  Requirements 

The  federal  government  does  not  regulate 
addiction  treatment  facilities  or  programs,  with 
the  exception  of  those  that  provide  opioid 
maintenance  therapy. 149  However,  the  federal 
government  imposes  certain  conditions  of 
participation  on  qualifying  programs  and 
facilities  through  federal  health  insurance 
programs,  including  Medicare,  Medicaid, 
TRICARE  for  members  of  the  active  duty 
military  and  the  veterans'  health  insurance 
program  (CHAMP  VA)— whether  they  are 
mainstream  health  care  or  addiction  treatment 
providers.150  Like  state  licensing  laws,  these 
provisions  include  requirements  regarding 
staffing,  services  and  quality  assurance 
mechanisms. 

To  be  eligible  to  receive  Medicare/Medicaid 
reimbursement,  most  treatments  must  be 
provided  by  or  under  the  supervision  of  a 
physician.151  State  Medicaid  programs  have  the 
option  of  covering  addiction  treatment  under  the 
Medicaid  rehabilitation  option,  Medicaid  clinic 
services,  targeted  case  management  and 
Medicaid  managed  care  waiver  programs.  The 
rehabilitation  option  is  the  most  flexible  for 
treatment  coverage  in  that  it  does  not  require 
services  to  be  medically  provided  or 
supervised.152  The  Medicare/Medicaid 
Conditions  of  Participation  impose  extensive 
requirements  on  participating  facilities  including 
staffing,  services  and  quality  assurance 

•  •         t  153 

provisions. 


*  A  few  states  qualified  the  licensing  requirement, 
saying  that  it  only  applied  to  certain  types  of  facilities 
(e.g.,  one  state  noted  that  the  requirement  was  for 
residential  treatment  facilities  only). 
'  Exemptions  appear  to  apply  to  programs  that  solely 
are  spiritual  or  religious  in  nature. 


1  In  addition,  under  the  Government  Performance 
Results  Act  (GPRA)  of  1993,  federally-operated 
programs  or  those  that  receive  federal  funds  for 
addiction  treatment  are  required  to  meet  certain 
reporting  requirements. 


-189- 


All  opioid  maintenance  therapy  facilities  are 
required  by  federal  law  to  obtain  certification 
from  the  U.S.  Department  of  Health  and  Human 
Services'  Substance  Abuse  and  Mental  Health 
Services  Administration  (SAMHSA) 
demonstrating  compliance  with  established 
standards  for  opioid  maintenance  therapy 
programs.154  It  is  a  pre-requisite  of  certification 
that  a  program  be  accredited  by  an  organization 
approved  by  SAMHSA.*  155 

Accreditation  Requirements 

In  lieu  of  or  in  addition  to  state  licensure, 
addiction  treatment  facilities  and  programs  may 
be  accredited  by  a  national  accreditation 
organization.  While  adopting  these  standards 
largely  is  voluntary,156  some  states  grant  licenses 
to  programs  that  have  been  accredited,157  such 
that  the  program  is  deemed  to  have  met  the  state 
licensure  requirements  because  it  has  been 
approved  by  a  national  accrediting  body.'  158  By 
granting  "deemed  status"  licenses  to  accredited 
programs,  the  state  essentially  delegates  to  the 
accrediting  body  its  responsibility  for  ensuring 
that  the  facility  or  program  meets  state  licensure 
requirements.159  Accreditation  standards  are 
more  detailed  than  state  licensing  requirements 
and  while  some  require  facilities  and  programs 
to  use  evidence-based  practices  or  to  analyze 
patient  outcomes,160  not  all  do.  Furthermore, 
accreditation  standards  do  not  require  staff  to  be 
qualified  to  provide  a  full  range  of  evidence- 
based  treatment,  and  accreditation  does  not 
necessarily  ensure  that  quality  care  is 
delivered.161 

The  accreditation  process  entails  a  review  of  the 
facility's  or  program's  structure  and  operational 
practices  and  evaluation  of  the  organization's 
clinical  care  processes  and  outcomes  to  confirm 
that  they  comply  with  standards  set  by  the 


To  be  approved  by  SAMHSA  to  accredit  opioid 
maintenance  therapy  programs,  an  accrediting 
organization  must  demonstrate  how  its  accreditation 
process  will  ensure  that  programs  meet  the  standards 
described  in  federal  regulations. 
'  Select  examples  of  states  that  allow  providers  to 
have  deemed  status  for  state  license  or  require 
accreditation  for  Medicaid  include:  AL,  AK,  AZ,  AR, 
CT  and  DE. 


accrediting  body.     Accreditation  generally  is 
considered  a  higher  standard  of  oversight  than 
state  licensing,  in  that  it  incorporates  "ideal  or 
optimum"  standards  rather  than  minimum 
standards,  and  focuses  on  continuous  quality 
improvement.163 

A  2007  study  of  the  association  between 
accreditation  and  nine  indicators  of  quality  care 
(categorized  as  staff-to-patient  ratio,  treatment 
comprehensiveness  and  treatment  sufficiency)  in 
566  outpatient  addiction  treatment  programs 
found  only  several  correlations  between 
accreditation  and  quality  of  care  measures.164 
Another  study  that  examined  the  adoption  of 
evidence-based  dosing  practices  in  methadone 
maintenance  programs  found  that  voluntary 
accreditation  was  strongly  related  to  adoption  of 
these  practices;  however,  after  accreditation 
became  mandatory  in  2000,  this  relationship 
disappeared.  The  authors  speculated  that 
programs  that  voluntarily  seek  accreditation  tend 
to  be  resource-rich  (in  funds,  staff  and  training) 
and  more  motivated  to  improve  their  quality  of 
care,  and  therefore  more  likely  to  adopt 
evidence-based  practices.165 

The  five  organizations  that  accredit  addiction 
treatment  programs  and  facilities  in  the  United 
States  are: 

•  The  Commission  on  Accreditation  of 
Rehabilitation  Facilities  ( CARF).  CARF  is 
an  independent,  nonprofit  organization  that 
offers  accreditation  for  addiction  treatment 
programs  and  facilities  and  integrated 
addiction/mental  health  treatment  programs 
and  facilities;  it  is  the  largest  accreditor  of 
addiction  treatment  programs  and 
facilities.166  CARF  accreditation  is  widely 
accepted  by  state  licensing  agencies  toward 
the  fulfillment  of  licensing  requirements  for 
addiction  treatment  programs  and 
facilities.167 

•  The  Joint  Commission  on  Accreditation  of 
Healthcare  Organizations  (Joint 
Commission).  The  Joint  Commission  is  the 
largest  accreditor  of  all  health  care  services 
in  the  U.S.168  and  the  second  largest 
accreditor  of  addiction  treatment  programs 


-190- 


and  facilities.169  Joint  Commission 
accreditation  is  widely  accepted  by  state 
licensing  agencies  toward  the  fulfillment  of 
licensing  requirements  for  addiction 
treatment  programs  and  facilities.170 

•  The  Council  on  Accreditation  (CO A).  COA 
is  an  international  accrediting  organization. 
Originally  known  for  accrediting  family  and 
children  services  agencies,  COA  currently 
accredits  numerous  services,  including 
addiction  treatment.171  COA  accreditation  is 
accepted  by  fewer  states  (approximately  1 0) 
relative  to  accreditation  by  CARF  or  the 
Joint  Commission.172 

•  The  National  Committee  for  Quality 
Assurance  (NCQA).  NCQA  is  a  nonprofit 
health  care  quality  improvement 
organization  that  accredits  health  care 
organizations.173  As  of  2005,*  Florida  and 
Michigan  were  the  only  states  that  accepted 
NCQA  accreditation  as  fulfilling  licensing 
requirements  for  addiction  treatment 
programs  and  facilities.174 

•  The  National  Commission  on  Correctional 
Health  Care  (NCCHC).  The  NCCHC  is  the 
only  organization  authorized  by  the  federal 
government  to  accredit  opioid  maintenance 
therapy  programs  that  specialize  in 
correctional  settings.175 

Of  the  13,339  addiction  treatment  programs  and 
facilities  voluntarily  responding  to  a  national 
survey 


.t 


56.9  percent  (7,595  facilities)  are  not 
accredited  by  CARF,  the  Joint  Commission, 
COA  or  NCQA; 

21.8  percent  (2,909  facilities)  are  accredited 
by  CARF; 


19.2  percent  (2,556  facilities)  are  accredited 
by  the  Joint  Commission; 

5.0  percent  (664  facilities)  are  accredited  by 
COA;  and 

2.8  percent  (371  facilities)  are  accredited  by 
NCQA. 


176 


Professional  Staffing  Requirements 

In  licensing  standards  for  medical  facilities, 
physicians  generally  are  responsible  for  patient 
care.*  177  In  contrast,  addiction  treatment  may  be 
provided  not  only  by  people  who  lack  medical 
training,  but  by  individuals  with  no  license  and 
no  graduate  education  or  clinical  training  at 
all.178 

State  licensing  laws,  federal  requirements  and 
accreditation  standards  regarding  which 
professionals  may  provide  and  supervise 
addiction  treatment  services  in  facilities  and 
programs  vary  significantly.  While  some  states 
require  addiction  treatment  programs  to  have  a 
medical  director  who  is  an  M.D.  on  staff,  others 
impose  minimum  education/training 
requirements  on  directors,  supervisors  and  staff. 
Accreditation  standards  do  not  recognize 
addiction  treatment  generally  as  requiring 
medical  care;  rather,  they  only  require  physician 
oversight  for  certain  services,  deferring  to  states 
with  regard  to  which  professionals  are  qualified 
to  provide  addiction  treatment.  Similarly, 
federal  requirements  stipulate  that  some  types  of 
care  must  be  provided  under  the  supervision  of  a 
physician,  while  services  such  as  "rehabilitation 
services"  do  not  require  supervision  by  a 
physician.179 

State  Staffing  Requirements.  In  licensing 
regulations  for  addiction  treatment  facilities  and 
programs,  states  typically  specify: 


The  most  recent  data  available.  More  states  may 
currently  accept  the  accreditation. 
1  The  National  Survey  of  Substance  Abuse  Treatment 
Services  (N-SSATS).  Accreditation  by  the  NCCHC 
was  not  measured  in  the  survey.  The  categories  are 
not  mutually  exclusive,  as  programs  and  facilities 
may  have  multiple  accreditations. 


1  Dentists  and  other  health  professionals  may  be 
responsible  for  services  they  are  qualified  to  perform 
or  supervise. 


-191- 


•  A  wide  range  of  "qualified  providers"  (e.g., 
addiction  counselors,  social  workers,  nurses) 
who  may  offer  and/or  supervise  treatments- 
most  of  whom  are  not  qualified  to  provide 
medical  care  or  are  not  trained  in  addiction; 

•  The  total  proportion  of  patient  care  that  must 
be  provided  by  "qualified  providers";  and 

•  The  ratio  of  staff  to  patients.180 

Although  state  licensing  requirements  allow  an 
array  of  practitioners  to  provide  addiction 
treatment,  the  licensing  requirements  for 
addiction  treatment  facilities  and  programs 
typically  state  that  "medical  services"  must  be 
provided  or  supervised  by  a  physician;  however, 
medical  services  are  defined  as  detoxification, 
opioid  replacement  therapy  or  the  assessment, 
diagnosis  and  treatment  of  co-occurring  medical 
or  mental  health  conditions,  not  as  addiction 
treatment  itself.181 

According  to  CASA  Columbia's  review,  43 
states  require  non-hospital-based1  outpatient  and 
residential  addiction  treatment  programs  to 
employ  (at  least  part  time)  a  physician  to  serve 
either  as  medical  director  or  on  staff;  however, 
this  requirement  applies  primarily  to  programs 
that  provide  opioid  maintenance  therapy  which, 
by  federal  regulation,  must  be  supervised  by  a 
physician.182  Few  states  require  non-hospital- 
based  programs  that  do  not  provide  opioid 
maintenance  therapy  to  have  a  physician  serving 
as  medical  director  or  on  staff;  1 0  states  require 
residential  treatment  programs  to  have  a 
physician  either  as  a  medical  director  or  on  staff 
and  eight  states  require  the  same  of  outpatient 
treatment  programs.  Without  a  physician  as 
medical  director  or  on  staff,  addiction  treatment 
programs  cannot  provide  a  full  range  of 
evidence-based  treatment  services  including 


Qualified  providers  are  those  who,  under  state  law, 
may  provide  addiction  treatment. 
'  See  section  on  Licensing  and  Credentialing 
Requirements  for  Individuals  who  Provide  Addiction 
Treatment,  above. 

*  Hospital  licensing  requirements  require  physician 
supervision  of  patient  care;  however,  the  majority  of 
addiction  services  offered  are  not  hospital  based. 


pharmaceutical  therapy  and  treatment  of  co- 
occurring  health  conditions. 

Consistent  with  these  requirements,  addiction 
treatment  services  typically  are  not  required  to 
be  supervised  by  a  physician,  other  than  for  the 
provision  of  narrowly-defined  "medical 
services."  While  states  may  require  that 
addiction  services  be  overseen  by  a  clinical  or 
program  director,  that  position  is  not  required  to 
be  filled  by  a  physician. 

Approximately  two-thirds  of  states  in  CASA 
Columbia's  review  specify  that  residential 
treatment  programs  (3 1  states)  and  outpatient 
treatment  programs  (29  states)  must  have  a 
program  or  clinical  director.  Among  the  2 1 
states  that  specify  the  minimum  educational/ 
training  requirements  for  this  position,  few  have 
particularly  high  standards: 

•  Eight  states  require  a  minimum  of  a  master's 
degree; 

•  Six  states  require  the  director  to  be  a 
licensed  or  certified  addiction  counselor; 

•  Four  states  require  a  minimum  number  of 
years  of  experience;5 

•  One  state  requires  a  bachelor's  degree; 

•  One  state  requires  an  associate's  degree;  and 

•  One  state  simply  requires  the  person  to 
demonstrate  competence  to  perform  certain 
services. 

A  national  survey  of  treatment  professionals 
conducted  in  1998  found  that  60.6  percent  of 
individuals  who  were  responsible  for 
supervising  clinical  services  in  addiction 
treatment  facilities  had  graduate  degrees  and 
77.5  percent  of  these  supervisors  were  certified 
or  licensed  as  addiction/mental  health 
professionals.  Among  facility  directors,  64.0 
had  a  graduate  degree  and  68.9  percent  were 


s  AZ  additionally  specifies  that  the  individual  must 
have  a  high  school  diploma  or  GED. 


-192- 


certified  or  licensed  as  addiction/mental  health 
professionals.183 

CAS  A  Columbia's  survey  of  directors*  of 
addiction  treatment  programs  in  New  York  State 
found  that  67.5  percent  had  a  graduate  degree, 
16.9  percent  had  a  bachelor's  degree,  14.5 
percent  had  some  college  or  an  associate's 
degree  and  1 .2  percent  had  only  a  high  school  or 
GED  degree.184 

Although  state  licensing  laws  sometimes  dictate 
that  clinical  supervisors,  such  as  program  or 
medical  directors,  have  special  training 
(including  certification)  or  experience  in 
addiction  treatment,185  they  generally  allow 
facilities  more  flexibility  to  determine  the 
necessary  qualifications,  including  level  of 
experience,  education  or  training,  as  well  as  the 
composition  of  other  clinical  staff186 

Federal  Staffing  Requirements.  In  states  that 
provide  addiction  treatment  using  Medicaid 
funding,  hospital  and  clinic  services  must  be 
provided  under  the  direction  of  a  physician,187 
but  if  states  choose  to  provide  services  under  the 
optional  benefits  category  of  rehabilitative  care, 
they  are  exempt  from  this  requirement.188  If 
services  are  required  to  be  provided  under  the 
direction  of  a  physician,  the  facility  physician  is 
not  required  to  be  on  staff  full  time,  but  must  be 
present  for  sufficient  time  to  provide  medical 
direction,  care  and  consultation  in  accordance 
with  accepted  principles  of  medical  practice. 
The  facility  and  the  staff  providing  care  also  are 
required  to  hold  appropriate  state  licenses, 
certifications  or  registrations.189 

The  federal  regulations  for  opioid  maintenance 
therapy  programs  specify  that  each  program 
must  employ  a  medical  director  and  that  all 
providers,  including  addiction  counselors, 
comply  with  the  credentialing  requirements  of 
their  respective  profession.190 


Some  of  the  program  directors  also  may  have 
served  as  clinical  supervisors,  but  the  survey  did  not 
distinguish  between  the  two  roles. 


Accreditation  Requirements  Regarding 
Staffing.1  CARF  standards  require  that 
programs  that  offer  detoxification,  inpatient 
care,  partial  hospitalization,  residential  treatment 
serving  "persons  with  medical  needs"  or  opioid 
maintenance  therapy  have  a  medical  director 
who  is  a  physician.  Organizations  that  seek 
elective  accreditation  for  assertive  community 
treatment  (ACT)*  services  must  have  a  physician 
on  staff.  Other  services  do  not  require  physician 
supervision. 191 

While  CARF  requires  staff  to  be  licensed  or 
certified  by  a  credentialing  body  that  uses  a 
competency-based  process,5  it  leaves  the 
determination  of  which  practitioners  are 
qualified  to  provide  addiction  treatment  to  state 
laws  and  professional  associations,  thus 
allowing  for  great  variation  in  education  and 

192 

training  requirements. 

The  Joint  Commission  allows  programs  to 
define  the  qualifications  required  for  staff  to 
perform  their  job  and  requires  staff  who  provide 
care  to  be  licensed,  certified  or  registered  "in 
accordance  with  the  law."  Only  opioid 
maintenance  therapy  programs  must  have  a 
physician  on  staff;  this  person  must  have 
experience  in  addiction  medicine,  including 
medication-assisted  treatment.193 

Treatment  Service  Requirements 

Licensed  health  care  facilities  must  deliver  care 
that  meets  standards  of  medical  practice;  state 
regulations  tend  to  defer  to  health  care 
providers— for  whom  there  are  well-delineated 
standards  of  education  and  training  in  health 
care  practice— to  determine  appropriate  medical 
practice  (e.g.,  which  services  to  provide  and  how 
to  provide  them).194  In  contrast,  those  who 
provide  addiction  treatment  often  have  minimal 


'  CASA  Columbia  reviewed  the  standards  of  the  two 
largest  accreditors  of  addiction  treatment  programs— 
CARF  and  the  Joint  Commission. 
*  As  described  in  Chapter  VI,  ACT  is  a  treatment 
approach  for  patients  with  co-occurring  addiction  and 
mental  health  conditions. 

§  Focused  on  the  ability  to  demonstrate  adequate 
skills,  knowledge  and  capacity  to  perform  a  specific 
set  of  job  functions. 


-193- 


education  or  training  in  addiction  science,  and 
there  are  no  accepted  standards  of  practice  that 
apply  across  facilities  and  programs.195 

While  most  states  regulate  addiction  treatment 
services,  they  treat  these  services  as  completely 
separate  and  distinct  from  medical  care,*  196  and 
state  regulations  regarding  addiction  treatment 
service  requirements  vary  considerably  and  tend 
to  be  vague.  Accreditors  specify  required 
services  in  greater  detail  than  state  licensing 
regulations,  as  do  the  federal  requirements  for 
facilities  providing  opioid  maintenance  therapy. 

State  Services  Requirements.  According  to 
CASA  Columbia's  review,  the  majority  of  states 
regulate  the  content  of  addiction  services  by 
requiring  adherence  to  specific  guidelines,  but 
the  extent  of  the  regulation  varies  considerably.1 
In  addition  to  listing  the  types  of  required 
services,  the  frequency  and  timing  of  services 
are  specified  in  some  cases;  for  example, 
patients  receiving  detoxification  must  receive  a 
psychosocial  assessment  within  72  hours  of 
admission197  or  patients  in  intensive  outpatient 
programs  must  receive  individual  or  group 
therapy  for  a  minimum  of  six  hours  over  at  least 
two  days  a  week.198 

More  than  30  states  require  addiction  treatment 
programs  and  facilities  to  utilize  the  American 
Society  of  Addiction  Medicine  (ASAM)  patient 
placement  criteria,  which  guide  providers  in 
matching  patient  needs  to  specific  treatment 
services  and  determining  the  appropriate  level  of 
care  for  patients.199 

State  regulations  related  to  addiction  treatment 
services  tend  to  specify  the  categories  of 
services  that  addiction  facilities  and  programs 
must  offer— such  as  individual,  family  and  group 


Except  for  opioid  maintenance  therapy  and  some 
detoxification  services,  which  are  considered  medical 
care  and  must  be  supervised  by  a  physician. 
'  Regulations  were  considered  to  provide  detailed 
guidelines  if  they  included,  for  example,  specific 
pharmaceutical  dosing  schedules  or  specific 
assessment  criteria  (e.g.,  including  onset/duration  of 
problems,  previous  interventions/outcomes,  health 
history/current  medical  care  needs  and  daily  living 
skills). 


counseling;  alcohol  and  other  drug  education; 
activity  therapy  and  social  services200~but  are 
not  particularly  specific  in  requiring  that  the 
services  follow  evidence-based  practices.  A 
survey  conducted  in  2006  found  that  three 
states— Oregon,  North  Carolina  and  Alaska- 
have  enacted  legislation  that  mandate  or 
encourage  the  use  of  evidence-based  practices  in 
addiction  treatment  programs;  only  Oregon 
mandates  programs  to  implement  evidence- 
based  practices  under  penalty  of  fiscal 
sanctions.201  However,  the  reach  of  the  Oregon 
law  is  limited  to  programs  and  facilities  that  are 
funded  by  the  state.1 202 

Federal  Services  Requirements.  The  federal 
regulations  for  opioid  maintenance  therapy 
programs  include  specific  admission  criteria, 
services  and  procedures  for  patient  care. 
Admission  is  limited  to  patients  who  meet 
clinical  diagnostic  criteria  for  opioid 
dependence1*  and  the  person  must  currently  have 
addiction  and  must  have  become  addicted  within 
one  year  before  treatment  admission.  A 
physician  must  perform  a  full  medical 
examination  before  admission.  Opioid 
maintenance  therapy  programs  must  provide 
medical  care,  addiction  counseling,  vocational 
and  educational  services  and  other  assessment 
and  treatment  services.  The  regulations  stipulate 
that  random  testing  for  addictive  drugs  must  be 
performed  on  all  patients  periodically; ' '  that 
treatment  medication  dosing  must  be  calculated 
by  a  physician  familiar  with  the  "most  up-to- 
date"  labeling;  and  that  for  patients  receiving 


1  The  Department  of  Corrections,  the  Oregon  Youth 
Authority,  the  State  Commission  on  Children  and 
Families  and  the  part  of  the  Oregon  Health  Authority 
that  deals  with  mental  health  and  addiction  issues. 
§  Determined  using  accepted  clinical  criteria,  such  as 
those  in  the  DSM-IV. 

**  The  one -year  requirement  may  be  waived  for 
persons  released  from  penal  institutions  (within  six 
months  after  release),  pregnant  women  (a  program 
physician  must  certify  pregnancy)  or  previously- 
treated  patients  (up  to  two  years  after  discharge). 
tt  All  patients  are  to  be  drug  tested  initially  and  then 
eight  times  per  year  for  patients  in  maintenance 
treatment  and  monthly  for  persons  receiving  long- 
term  detoxification  treatment. 


-194- 


methadone,  the  initial  dose  cannot  exceed  30 
milligrams.203 

Accreditation  Service  Requirements. 

Accreditation  organizations  delineate  detailed 
specifications  related  to  addiction  services 
provided  by  facilities  and  programs. 

CARF  requires  that  addiction  services  be 
evidence  based,  explicitly  stating  that  care 
should  incorporate  "current  research,  evidence- 
based  practice,  peer-reviewed  scientific  and 
health  publications,  clinical  practice  guidelines 
and/or  expert  professional  consensus."  The 
facility  must  have  written  policies  regarding 
service  delivery  including  screening,  referrals, 
medication  use  and  control,  discharge  and 
follow  up. 204  CARF  sets  forth  procedural 
requirements  for  the  above  services,  as  well  as 
orientation,  assessment  and  the  development  of 
"person-centered  plans"  for  treatment. '  CARF 
offers  accreditation  standards  for  each  of  the 
"core  program  areas"  that  programs  and 
facilities  may  elect  to  have  accredited,  such  as 
assertive  community  treatment  (ACT), 
community  integration,1  detoxification,  day 
treatment,  drug  court  treatment,  partial 
hospitalization  and  inpatient  services.  Standards 
for  the  core  program  areas  are  very  detailed  and 
cover  which  services  must  be  provided,  by 
whom  and  how  often. §  205 


The  process  of  physically  controlling,  transporting, 
storing  and  disposing  of  medications,  including  those 
that  are  self-administered  by  patients. 
'  Treatment  plans  developed  with  the  input  of 
patients  regarding  their  goals,  needs,  strengths, 
abilities,  preferences,  desired  outcomes  and  cultural 
background. 

*  A  form  of  treatment  that  provides  opportunities  for 
community  participation  as  a  means  of  optimizing 
personal,  social  and  vocational  competency  in  order 
to  live  successfully  in  a  community. 
§  For  example,  day  treatment  must  be  provided  at 
least  three  hours  a  day,  four  days  a  week;  must 
include  three  interventions  from  a  designated  list  of 
interventions  (e.g.,  family  therapy,  group  counseling, 
individual  psychotherapy,  occupational  therapy, 
alcohol  and  other  education)  plus  two  additional 
activities  (nutritional/fitness/leisure/social);  the 
program  must  be  directed  by  a  qualified  behavioral 
health  practitioner  (a  person  certified,  licensed, 
registered  or  credentialed  by  a  governmental  entity  or 


The  Joint  Commission  requires  facilities  to  have 
written  procedures  for  eligibility  for  admission 
and  for  most  services.  The  standards  for 
addiction  treatment  programs  include  procedural 
requirements  governing  essential  services  such 
as  screening  and  assessments;  medical 
history/physical  examinations;  screening  for 
physical  pain,  nutritional  status  and  signs  of 
trauma/abuse/neglect/exploitation;  special 
provisions  for  services  provided  to  vulnerable 
populations  (children,  individuals  with 
intellectual/developmental  disabilities);  care  that 
reflects  patients'  needs,  preferences  and  goals; 
coordination  of  care;  necessary  referrals; 
primary  physical  care;  and  discharge/transfer 
that  assures  continuity  of  care.206  The  standards 
do  not  specify  what  kind  of  psychosocial  or 
pharmaceutical  services  should  be  provided, 
leaving  much  room  for  variability  in  the  quality 
of  patient  care. 

Because  opioid  maintenance  therapy  is 
considered  "medical  care,"  Joint  Commission 
standards  for  opioid  maintenance  therapy 
programs  are  more  numerous  and  detailed.  For 
example,  such  programs  must  address  relapse 
prevention  in  discharge  planning;  use  DSM-IV 
or  other  accepted  clinical  criteria  to  diagnose 
addiction;  perform  an  initial  toxicology  test  and 
a  comprehensive  screening  of  patients'  medical 
conditions;  document  current  chronic  or  acute 
medical  conditions;  provide  hepatitis  A  and  B 
immunizations;  manage  current  misuse  of  other 
drugs  that  are  not  the  primary  focus  of 
treatment;  and  include  smoking  cessation  as  an 
integral  component  of  care.207 

Quality  Assurance  Requirements 

Quality  assurance  requirements  can  be  imposed 
by  state  and  federal  governments,  by  accreditors 
or  by  payers.  Such  requirements  focus  on 
assuring  specific  organizational  structures, 


a  professional  association  as  meeting  the 
requirements  necessary  to  provide  mental  health  or 
alcohol  and  other  drug  services);  screening  and 
assessments  must  be  provided;  and  when  psychiatric 
services  are  necessary,  a  psychiatrist  must  be 
available  24-hours  a  day. 


-195- 


processes  and  outcomes  as  ways  of  assuring 
quality.208 

Accreditation  of  health  care  facilities  tends  to 
focus  on  structural  measures  (e.g.,  physical  plant 
adequacy,  nursing  ratios,  certification  of 
providers,  availability  of  certain  services). 
While  patient  outcomes  (e.g.,  survival,  function, 
quality  of  life)  are  in  many  ways  the  most 
important  variables,  they  are  difficult  to  collect 
and  analyze.  Patient  outcomes  may  be  affected 
by  factors  independent  of  the  quality  of  a 
specific  health  care  service  delivered,  including 
co-occurring  conditions,  patient  compliance  and 
lifestyle.  Outcome  data  also  are  subjective  and 
vary  according  to  the  setting  and  the  particular 
instruments  used  to  measure  them.  Given  these 
barriers,  quality  assurance  efforts  tend  to  focus 
on  the  process  of  care,  which  examines  the 
frequency  with  which  interventions  known  to 
correlate  with  positive  outcomes  are 
performed.209 

State  Quality  Assurance  Requirements.  State 
quality  assurance  requirements  for  addiction 
treatment  programs  and  facilities  are  highly 
variable  and  focus  mainly  on  process.  For 
example,  a  program  that  is  run  efficiently  and 
maintains  good  records  would  be  considered  a 
quality  program  regardless  of  patient  outcomes. 

CASA  Columbia's  state-by-state  analysis  of 
regulations  and  statutes  found  that  45  states  have 
some  type  of  quality  assurance  requirements  for 
addiction  treatment  facilities  and  programs, 
although  this  may  take  the  form  of  simply 
requiring  the  establishment  of  a  quality 
improvement  plan.  Fewer  than  half  of  these 
states  (2 1  states)  have  explicit  requirements  that 
patient  outcome  data  be  collected  but,  even  for 
those  that  do,  the  types  of  data  required  rarely 
are  specified.  Four  of  the  states  that  require  the 
collection  of  patient  outcome  data  have 
explicitly-defined  categories  of  such  data,  but 
these  categories  focus  primarily  on  reductions  in 
specific  types  of  substance  use  or  its 
consequences-such  as  reduction  or  elimination 
of  the  use  of  illicit  drugs,  reduction  or 
elimination  of  associated  criminal  activities  or 
improvement  of  quality  of  life.  The  absence  of 
other  indicators  linked  to  improved  health  and 


function  or  effective  disease  management  is 
noticeably  absent. 

CASA  Columbia's  review  found  little  evidence 
that  states  impose  sanctions  on  facilities  that  fail 
to  meet  the  outcome  reporting  requirements  and, 
for  those  that  do,  the  penalties  are  minor  (e.g.,  a 
$100  fine). 

Federal  Quality  Assurance  Requirements. 

Federal  quality  assurance  requirements  vary  by 
program.  Federal  Medicare/Medicaid  conditions 
of  participation  address  quality  assurance  issues 
by  requiring  utilization  review  committees  to 
assure  compliance  with  written  procedures  for 
evaluating  admissions,  continued  care  and 
discharges;  linking  treatment  plans  to 
established  goals;  clinical  record  keeping;  and 
requiring  that  the  group  of  professionals  within 
the  program  or  facility  that  develops  patient  care 
policies  review  and  act  upon  recommendations 
from  the  utilization  review  committee.210 

The  federal  regulations  for  opioid  maintenance 
therapy  programs  require  continual  quality 
assurance  measures  which  must  include  ongoing 
assessment  of  patient  outcomes  (not  specified) 
and  annual  review  of  program  policies  and 
procedures.211 

All  federal  agencies  that  operate  programs  or 
provide  funds  related  to  addiction  treatment  are 
required  to  report  on  the  performance  of  those 
programs  in  accordance  with  the  Government 
Performance  Results  Act  (GPRA)  of  1993.  In 
order  to  fulfill  their  requirements  under  the  Act, 
each  federal  agency  must  develop  a  strategic 
plan  (including  annual  performance  targets) 
covering  each  of  their  programs,  conduct 
evaluations  to  assess  how  well  a  program  is 
working  and  why  particular  outcomes  have  (or 
have  not)  been  achieved  and  produce  program 
performance  reports  based  on  analyses  of 
program  effectiveness.212 

SAMHSA  is  the  leading  federal  agency  that 
funds  addiction  treatment;  it  administers  the 
Substance  Abuse  Prevention  and  Treatment 
Block  Grant  (SAPTBG),  a  federal  grant  that 
funds  state  prevention,  treatment,  recovery 


-196- 


supports  and  other  services.       SAPTBG  is  a 
major  source  of  funding  for  state-run  or  state- 
funded  treatment  programs.214  SAMHSA's 
performance  targets  and  outcome  measures  for 
this  program  include  required  data  collection 
and  reporting  on  the  number  of  admissions  to 
treatment  programs  receiving  public  funding  and 
on  outcomes,  including  abstinence^ 
employment,  school  enrollment,  justice  system 
involvement  and  housing.215 

Accreditation  Requirements  for  Quality 
Assurance.  CARF  requires  addiction  treatment 
facilities  and  programs  to  conduct  a  records 
review  to  assess  the  quality  and  appropriateness 
of  services  provided,  as  well  as  a  review  of  the 
patterns  of  service  utilization.  Programs  must 
analyze  patient  outcomes— including  abstinence; 
reduction  in  relapse,  criminal  activity  and 
hospitalizations;  improved  psychological 
function;  housing  situation;  employment  status— 
to  determine  the  effectiveness  of  services.216 

Joint  Commission  standards  for  addiction 
treatment  facilities  and  programs  focus  more  on 
performance  improvement  measures  by 
requiring  programs  to  conduct  data  collection 
and  data  analysis  and  to  identify  any 
opportunities  for  improving  performance  (e.g., 
in  reducing  errors,  incorporating  patient  goals  or 
comparison  with  external  quality  measures). 
Only  opioid  maintenance  therapy  programs  are 
required  specifically  to  collect  outcome  data, 
which  include  measures  of  the  use  of  illicit 
opioids,  criminal  involvement,  health  status, 
retention  in  treatment  and  abstinence.217 


States  that  receive  SAPTBG  funds  must,  among 
other  things:  spend  five  percent  of  the  funds  on 
increasing  treatment  capacity  for  pregnant  women 
and  women  with  dependent  children  by  establishing 
new  programs  or  expanding  the  capacity  of  existing 
programs,  improve  the  process  for  referring 
individuals  to  treatment  facilities  that  can  provide  the 
most  appropriate  treatment  modality,  and  make 
continuing  education  available  to  employees  of 
funded  facilities. 

'  Measures  of  client  abstinence  reflect  no  past-month 
use  of  alcohol  or  other  drugs  at  discharge.  Discharge 
is  defined  as  the  date  of  last  service. 


-198- 


Chapter  X 

The  Evidence-Practice  Gap 


The  prevention  and  reduction  of  the  risky  use  of 
addictive  substances  and  the  treatment  of 
addiction,  in  practice,  bear  little  resemblance  to 
the  significant  body  of  evidence-based  practices 
that  have  been  developed  and  tested;*  indeed 
only  a  small  fraction  of  individuals  receive 
interventions  or  treatment  consistent  with 
scientific  knowledge  about  what  works.1 

Providing  quality  care  to  identify  and  reduce 
risky  use  and  diagnose,  treat  and  manage 
addiction  requires  a  critical  shift  to  science- 
based  interventions  and  treatment  by  medical 
professionals— both  primary  care  providers  and 
specialists. 

Significant  barriers  stand  in  the  way  of  making 
this  critical  shift,  including  an  addiction 
treatment  workforce  that  is  largely  unqualified 
to  implement  evidence-based  practices;  a  health 
professional  that  should  be  responsible  for 
providing  addiction  screening,  interventions, 
treatment  and  management  but  does  not 
implement  evidence-based  addiction  care 
practices;  inadequate  oversight  and  quality 
assurance  of  treatment  providers  and 
intervention  practices;  limited  advances  in  the 
development  of  pharmaceutical  treatments;  and 
a  lack  of  adequate  insurance  coverage. 

Recent  efforts  by  government  agencies  and 
professional  associations  have  begun  to  tackle 
these  challenges  to  closing  the  evidence-practice 
gap,  but  are  insufficient. 

Current  Approaches  to  Risky 
Substance  Use  and  Addiction  Are 
Inconsistent  with  the  Science  and 
with  Evidence-Based  Care 

Unlike  other  public  health  problems  and 
diseases  that  are  met  with  qualified  medical  care 


See  Chapters  IV- VI. 


-199- 


and  cutting-edge  interventions,  the  reigning 
paradigm  in  the  health  community  for 
addressing  risky  substance  use  and  addiction  is 
to  fail  to  address  the  problem  directly.  Instead, 
risky  users  of  addictive  substances  are  in  most 
cases  sanctioned  in  terms  of  the  consequences 
that  result— such  as  accidents,  crimes,  domestic 
violence,  child  neglect  or  abuse-while  effective 
interventions  to  reduce  risky  use  rarely  are 
provided.  Those  with  addiction  frequently  are 
referred  to  support  services,  often  provided  by 
similarly-diagnosed  peers  who  struggle  with 
limited  resources  and  no  medical  training,  to 
assist  them  in  abstaining  from  using  addictive 
substances.  While  social  support  approaches  are 
helpful  and  even  lifesaving  to  many-and  can  be 
important  supplements  to  medically-supervised, 
evidence-based  interventions— they  do  not 
qualify  as  treatment  for  a  medical  disease. 

In  short,  the  gap  between  the  evidence  regarding 
what  works  in  interventions  for  risky  substance 
use  and  in  the  treatment  and  management  of 
addiction  versus  on-the-ground  practice  is  wide, 
and  nothing  short  of  a  significant  overhaul  in 
current  approaches  is  required  to  bring  practice 
in  line  with  the  evidence  and  with  the  standard 
of  care  for  other  public  health  and  medical 
conditions. 

While  a  wide  range  of  trained  health 
professionals  can  screen  for  risky  use  of 
addictive  substances  and  provide  brief 
interventions,  physicians  should  be  essential 
providers  of  the  full  range  of  addiction  treatment 
services.  They  should  provide  this  care  in 
collaboration  with  multiple  medical  specialties 
and  sub-specialties  and  a  multi-disciplinary  team 
of  health  professionals,  including  physician 
assistants,  nurses  and  nurse  practitioners  and 
graduate-level  clinical  mental  health 
professionals  (psychologists,  social  workers, 
counselors). 

Given  the  prevalence  of  addiction  in  society  and 
the  extensive  evidence  regarding  how  to 
identify,  intervene  and  treat  it,  continued  failure 
to  do  so  signals  widespread  system  failure  in 
health  care  service  delivery,  financing, 
professional  education  and  quality  assurance.  It 
also  raises  the  question  of  whether  the  low  levels 


of  care  that  addiction  patients  usually  do  receive 
constitutes  a  form  of  medical  malpractice. 

Patient  Education,  Screening,  Brief 
Interventions  and  Treatment  Referrals 

Despite  the  documented  benefits  of  screening 
and  early  intervention  practices,  medical  and 
other  health  professionals'  considerable 
potential  to  influence  patients'  substance  use 
decisions,  and  the  long  list  of  professional  health 
organizations  that  endorse  the  use  of  such 
activities,  most  health  professionals  do  not 
educate  their  patients  about  the  dangers  of  risky 
substance  use  or  the  disease  of  addiction,  screen 
for  risky  substance  use,  conduct  brief 
interventions  when  indicated,  treat  the  condition 
or  refer  their  patients  to  specialty  care  if 
needed.2 

Since  the  1950s,  screening  has  been  considered 
an  important  element  of  general  health  care  and 
as  early  as  1968,  the  World  Health  Organization 
(WHO)  laid  out  the  principles  of  early  disease 
detection.3  Based  on  those  principles,  risky 
substance  use  and  signs  of  addiction  are  highly 
conducive  to  screening  by  general  health 
practitioners:  they  are  significant  health 
problems  with  well-understood  natural  histories, 
there  are  non-invasive  tests  and  easily-detected 
symptoms  and  early  interventions  result  in 
favorable  outcomes.4  Unfortunately,  there  is  a 
considerable  gap  between  what  current  science 
suggests  constitutes  risky  substance  use  and  the 
thresholds  set  in  some  of  the  most  common 
screening  instruments  for  determining  that  an 
individual  meets  criteria  for  risky  substance  use 
and  is  in  need  of  intervention  (see  Chapter  IV). 

Medical  and  other  health  professionals  are  in 
ideal  positions  to  educate  patients,  conduct 
screening  and  brief  interventions  and  refer 
patients  to  treatment.  The  vast  majority  of 
adults  (82.2  percent)  and  children  (92.1  percent) 
had  regular  contact  with  a  health  professional  in 
20 10.5  There  are  many  venues  where  health 
professionals  can  conduct  patient  education, 
screening  and  brief  interventions  with  relative 
ease  and  most  patients  would  be  receptive  to 


See  Chapter  IV. 


-200- 


these  practices.6  These  include  primary  care 
medical  offices,  dental  offices,  pharmacies, 
school-based  health  clinics,  mental  health 
centers  and  clinics,  emergency  departments  and 
trauma  centers,  hospitals  or  encounters  with  the 
justice  system  due  to  substance-involved 
crimes.7 

Yet,  there  is  no  evidence  to  suggest  that  medical 
and  other  health  professionals  routinely  avail 
themselves  of  these  opportunities.8  To  the 
contrary,  a  2000  CASA  Columbia  survey  found 
that  only  32.1  percent  of  physicians  regularly  do 
even  one  of  the  following:  administer  a  health 
history  form  to  patients  at  least  annually  with 
one  or  more  substance  use  questions;  administer 
a  screening  instrument  to  detect  the  risky  use  of 
one  or  more  substances;  discuss  substance  use 
with  pregnant  patients;  or  "almost  always"  ask 
patients  about  their  substance  use  when  they 
suspect  a  patient  has  a  problem.9 


The  consequences  of  failure  to  identify  risky  use 
or  detect  signs  of  addiction  can  be  life 
threatening.  Mistaking  symptoms  of  risky 
substance  use  for  signs  of  other  conditions  may 
lead  to  a  misdiagnosis  or  to  prescribing 
medications  that  are  unnecessary,  produce 
dangerous  drug  interactions,  compound  an 
existing  addiction  problem*  or  create  additional 
health  risks. 1 1 


Thirty  percent  of  patient  respondents  in  CASA 
Columbia's  2000  survey  of  physicians  and  patients 
said  their  physician  knew  about  their  addiction  and 
still  prescribed  psychoactive  drugs  such  as  sedatives 
or  Valium. 


This  gap  between  evidence  and  practice  is 
particularly  acute  for  adolescents  because  of  the 
critical  importance  of  prevention  and  early 
intervention  in  this  population.  Screening  and 
intervention  services  by  health  professionals  for 
adolescents  rarely  is  part  of  routine  practice 
despite  the  abundance  of  guidelines  and 
recommendations  for  screening  this  population; 
the  knowledge  that  nearly  three  out  of  four  high 
school  students  have  used  tobacco,  alcohol  or 
other  drugs;  and  the  availability  of  effective 
interventions.12 

Current  Practices  Related  to  Tobacco.  The 

majority  (68.8  percent)  of  adults  who  are  current 
smokers  report  that  they  want  to  quit  smoking, f 
yet  less  than  half  (48.3  percent)  of  smokers  who 
saw  a  health  professional  in  the  past  year 
reported  receiving  advice  to  quit.1 13  A  survey 
of  6th"  through  12th-grade  students  found  that 
64.5  percent  reported  that  in  the  past  year  no 
medical  doctor,  dentist  or  nurse  asked  them 
whether  they  smoked  cigarettes,8  14  even  though 
screening  and  interventions  by  health 
professionals  can  have  a  substantial  impact  on 
young  smokers.15 

A  large-scale  analysis  of  national  data"  of 
clinical  preventive  services  delivered  to 
asymptomatic  patients  in  clinical  settings 
estimates  that  only  35  percent  of  the  population 
receives  tobacco  screening  and  brief 
interventions  in  accordance  with  the 


'  52.4  percent  of  current  and  former  smokers  (those 
who  quit  smoking  in  the  past  year  for  six  months  or 
longer)  had  made  a  quit  attempt  that  lasted  longer 
than  one  day  in  the  past  year;  however,  only  6.2 
percent  report  that  they  have  quit  successfully. 
*  Medicare  beneficiaries  were  the  most  likely  to 
receive  smoking  cessation  advice  (59.0  percent)  and 
those  without  health  insurance  were  the  least  likely  to 
receive  smoking  cessation  advice  (35.3  percent). 
§  CASA  Columbia's  analysis  of  data  from  that  survey 
found  that,  of  those  who  smoked,  only  21.4  percent 
said  that  these  health  professionals  told  them  to  stop 
smoking. 

**  Including  the  National  Health  Interview  Survey 
(NHIS),  the  Behavioral  Risk  Factor  Surveillance 
System  (BRFSS)  and  the  Healthcare  Effectiveness 
Data  and  Information  Set  (HEDIS)  performance  data. 


...Primary  care  physicians  do  not  routinely 
provide  any  comprehensive  screening  for 
substance  use  disorders. . .  [When  they  do  provide 
treatment  referrals,  however,  some  encounter] 
addiction  treatment  services  as  a  "black  hole  ". . . 
They  are  not  informed  of  patient  progress, 
treatment  completion  or  non-completion  or 
recommendations  for  continuing  care.  This 
contrasts  significantly  with  referrals  to  other 
specialists  wherein  the  treatment  is  regularly 
communicated  and  a  collaborative  relationship  is 
maintained. 10 


-201- 


recommendations  of  the  United  States 
Preventive  Services  Task  Force  (USPSTF).16 

Another  study  found  that  while  physicians  knew 
of  their  patients'  smoking  status  at  68  percent  of 
office  visits,  they  provided  smoking  cessation 
counseling  at  only  20  percent  of  visits  by 
smokers.17  Analysis  of  national  data  found  that 
physicians  provided  counseling  in  22.5  percent 
of  visits  by  current  adult  tobacco  users;  only  2.4 
percent  of  current  tobacco  users  were  prescribed 
medications  for  smoking  cessation.*  18  A 
national  survey  of  medical  professionals- 
including  primary  care  physicians,  emergency 
medicine  physicians,  psychiatrists,  registered 
nurses,  dentists,  dental  hygienists  and 
pharmacists— indicates  that  whereas  most  report 
asking  patients  if  they  smoke  and  advising  those 
who  smoke  to  quit,  they  are  much  less  likely  to 
follow  through  with  assessments  or  referrals  to  a 
smoking  cessation  program.19 

A  study  of  physicians  in  family  medicine, 
internal  medicine,  obstetrics/gynecology  and 
psychiatry  found  similar  results.  Although  most 
(86  percent)  report  asking  patients  about  their 
smoking  and  advising  them  to  quit,  few  do  much 
more  than  that:  only  1 7  percent  said  they 
usually  arrange  for  a  follow-up  visit  to  address 
the  patient's  smoking  and  only  13  percent  said 
they  usually  refer  patients  who  smoke  to 
appropriate  treatment.20  One  study  found  that 
pulmonologists,  cardiologists  and  family 
physicians  were  the  physician  specialists  most 
likely  to  be  familiar  with  resources  regarding 
treatment  for  addiction  involving  nicotine  and 
most  likely  to  refer  patients  to  treatment, 
whereas  psychiatrists,  neurologists, 
ophthalmologists  and  surgeons  were  the  least 
likely  to  have  such  familiarity  or  to  refer 
patients.21 

A  survey  of  clinical  psychologists  found  that 
one-third  (32.3  percent)  had  not  thought  about 
offering  smoking  cessation  counseling  to  their 
patients.22  And  although  most  registered  nurses 
ask  patients  about  smoking  (87.3  percent),  only 
65.6  percent  advise  those  who  smoke  to  quit  and 


Both  female  patients  and  patients  ages  65  and  older 
were  less  likely  to  be  prescribed  medication. 


less  than  half  offer  interventions  (49.4  percent 
provide  materials  with  quitline  information  and 
34.0  percent  refer  the  patient  to  a  smoking 
cessation  program).23  Another  national  survey 
of  nurses'  interventions  with  patients  who 
smoke  found  similar  results. '  24 

While  the  U.S.  Clinical  Practice  Guideline  on 
Treating  Tobacco  Use  and  Dependence 
encourages  dental  clinicians  to  screen  their 
patients  for  tobacco  use25  and  has  been 
promulgated  widely  by  the  United  States  Public 
Health  Service  and  the  Agency  for  Healthcare 
Research  and  Quality,  approximately  three  in  10 
dental  professionals  still  do  not  advise  patients 
who  smoke  to  quit  and  approximately  three- 
quarters  do  not  refer  a  patient  who  smokes  to  a 
smoking  cessation  program.26  This  is  despite  the 
fact  that  many  patients  expect  their  dentists  to 
inquire  about  their  smoking  status  and  to  discuss 
smoking  cessation  with  them;  30  percent  of 
dental  patients  report  that  they  would  try  to  quit 
smoking  if  their  dentist  suggested  they  do  so.27 
Dentists  who  implement  an  effective  smoking 
cessation  intervention  can  expect  that  up  to  10  to 
1 5  percent  of  their  patients  who  smoke  will  quit 
in  a  given  year.28 

Pharmacists,  as  a  profession,  rarely  provide 
tobacco  cessation  counseling;  only  about  seven 
percent  of  patients  report  being  asked  by  a 
pharmacist  about  tobacco  use.29  This  is  in  spite 
of  the  facts  that  pharmacists  are  one  of  the  most 
accessible  groups  of  health  professionals  and 
they  work  in  settings  frequented  by  smokers  and 
where  tobacco  cessation  products  are  available.30 
The  majority  of  smokers  (83  percent)  believe 
that  pharmacists  should  be  involved  in  providing 
smoking  cessation  interventions,  73  percent 
would  join  a  smoking  cessation  program  offered 
at  a  conveniently-located  pharmacy31  and  63 
percent  who  already  use  nicotine  replacement 
therapy  (NRT)  believe  that  smoking  cessation 
counseling  by  pharmacists  would  increase  a 


'  Seventy-three  percent  frequently  asked  patients 
about  tobacco  use  and  62  percent  advised  patients 
about  quitting.  Only  24  percent  of  nurses 
recommended  medications  to  patients  for  cessation, 
22  percent  referred  patients  to  cessation  resources 
and  10  percent  recommended  use  of  a  quitline. 


-202- 


smoker's  likelihood  of  being  able  to  quit.32 
Something  as  simple  as  keeping  NRT  products 
behind  the  pharmacy  counter  where  customers 
would  have  to  ask  for  them,  or  within  view  of 
the  pharmacist  but  accessible  to  customers,  is 
related  to  a  greater  likelihood  of  pharmacist- 
initiated  smoking  cessation  counseling.  In  one 
study,  pharmacists  who  stored  NRT  products 
behind  the  counter  were  4.7  times  likelier  to 
provide  counseling '  than  pharmacists  who  stored 
the  products  out  of  customers'  sight;  those  who 
stored  them  within  view  but  still  accessible  to 
customers  were  three  times  likelier  to  offer 
counseling  than  those  who  stored  them  out  of 
customers'  sight.33 

Current  Practices  Related  to  Alcohol  and 
Other  Drugs.  A  national  survey  of  patients 
who  had  visited  a  general  medical  provider  in 
the  past  year  found  that  only  29  percent  were 
asked  about  alcohol  or  other  drug  use;  9.2 
percent  were  given  the  suggestion  to  stop  using, 
13.6  percent  were  given  a  brief  intervention  and 
5.3  percent  were  referred  to  counseling.  Of 
those  in  the  sample  who  reported  having  been 
asked  by  a  general  medical  provider  about  their 
alcohol  or  other  drug  use  and  were  identified  as 
risky  drinkers,  less  than  half  (48.6  percent) 
received  any  type  of  advice  from  their  doctor 
concerning  their  substance  use.34 

Another  study  found  that  19.6  percent  of 
patients  who  were  identified  by  primary  care 
practitioners  as  misusing  addictive  substances 
but  who  were  not  diagnosed  with  addiction  did 
not  receive  a  recommendation  for  an  active 
intervention.35 

A  national  survey  of  current  and  former 
drinkers,  ages  18-39  years,  found  that  67  percent 
saw  a  physician  in  the  past  year  but  only  49 
percent  of  excessive  drinkers1  were  asked  about 


This  approach  might  be  less  likely  to  deter 
customers  from  purchasing  the  NRT  products,  since 
some  smokers  may  be  hesitant  to  ask  for  assistance. 
'  To  four  or  more  customers  per  month. 
*  Those  exceeding  the  National  Institute  on  Alcohol 
Abuse  and  Alcoholism's  (NIAAA)  guidelines  of  no 
more  than  four  drinks  per  day  or  14  drinks  per  week 
for  men  and  no  more  than  three  drinks  per  day  or 
seven  drinks  per  week  for  women. 


their  drinking  and  only  2 1  percent  of  them  were 
counseled  about  risky  drinking.5  While 
respondents  ages  18-25  years  were  most  likely 
to  engage  in  excessive  drinking,  they  were  least 
likely  to  be  asked  about  their  alcohol  use  (34 
percent  of  excessive  drinkers  ages  1 8  to  25  years 
vs.  54  percent  of  excessive  drinkers  ages  26  to 
39  years).36 

Efforts  to  educate  patients  and  connect  them 
with  needed  services  also  are  inadequate  in 
emergency  departments  (EDs).37  The  American 
College  of  Surgeons  Committee  on  Trauma 
designated  alcohol  and  other  drug  screening  as 
an  "essential  diagnostic  test"  at  Level  I  and 
Level  II  trauma  centers,38  yet  many  trauma 
centers  do  not  provide  any  screening  or  brief 
intervention  services  for  those  who  may  need 
them.39  A  national  survey  of  ED  directors  found 
that  only  1 5  percent  reported  having  formal 
screening  and  intervention  policies  in  their  EDs. 
While  nearly  two-thirds  (64.5  percent)  reported 
routinely  screening  for  risky  alcohol  use  via  a 
serum  alcohol  level  and  23.6  percent  reported 
using  standardized  screening  instruments,  only 
nine  percent  reported  offering  brief  interventions 
by  trained  personnel  for  risky  alcohol  use.40 

Although  the  majority  of  surgeons  (89  percent) 
say  that  alcohol  is  a  major  burden  on  their 
trauma  center  (an  estimated  40  to  50  percent  of 
trauma  patients  have  positive  blood  alcohol 
levels) 41  and  76  percent  consider  other  drug  use 
to  be  a  significant  burden,42  trauma  center  and 
ED  physicians  often  fail  to  address  the 
underlying  alcohol  and  other  drug  problems  that 
cause  patients'  injuries.43 

Despite  evidence  of  the  effectiveness  of  ED- 
based  screening  and  brief  interventions  for 
substance-using  adolescents,44  a  study  of 
adolescents  admitted  to  hospitals  following 
trauma  injuries  in  which  15.5  percent  screened 
positive  for  alcohol  in  their  blood  found  that 
only  59  percent  of  those  who  screened  positive 
were  referred  for  intervention  services.45 


14  percent  were  advised  about  low-risk  drinking 
guidelines  and  seven  percent  were  advised  to  cut 
down. 


-203- 


Assessment,  Stabilization  and  Acute 
Treatment 

Despite  the  existence  of  effective  assessment, 
stabilization  and  treatment  options,  addiction 
treatment  today  for  the  most  part  is  not  based  in 
the  science  of  what  works.46  Depending  on 
disease  stage  and  a  range  of  other  health  and 
social  factors,  some  people  with  addiction  may 
be  able  to  stop  using  addictive  substances  and 
manage  the  disease  with  support  services  only; 
however,  most  individuals  with  the  disease 
require  clinical  treatment.47  The  failure  of  many 
providers  to  properly  assess  the  stage  and 
severity  of  the  disease  and  provide  effective 
psychosocial  and  pharmaceutical  therapies 
appears  in  large  part  to  be  due  to  a  lack  of 
appropriate  education  and  training.* 48 

While  physicians  are  somewhat  better  at 
assessing  tobacco  use  among  their  patients  and 
discussing  options  for  treatment,  there  is  still 
much  room  for  improvement.  A  recent  national 
survey  found  that  approximately  two-thirds  of 
primary  care  physicians  (68.5  percent)  and 
psychiatrists  (63.8  percent)  report  discussing 
medication  options  for  smoking  cessation  with 
their  patients,  as  do  22.6  percent  of  dentists  and 
14.5  percent  of  emergency  medicine 
physicians.49 

CASA  Columbia's  2000  survey  of  physicians 
and  patients  found  that  94  percent  of  primary 
care  physicians  (excluding  pediatricians)  failed 
to  identify  addiction  as  a  possible  diagnosis 
when  asked  to  offer  five  possible  diagnoses  of  a 
patient  with  symptoms  of  risky  alcohol  use. 
Most  patients  responding  to  that  survey  (53.7 
percent)  reported  that  their  primary  care 
physician  did  nothing  about  their  addiction;  10.7 
percent  said  their  physician  knew  about  it  and 
still  did  nothing.  The  majority  of  patients  (74.1 
percent)  said  their  primary  care  physician  was 
not  involved  in  their  decision  to  seek  treatment 
and  16.7  percent  said  their  physician  was 
involved  only  "a  little."50 

CASA  Columbia's  research  also  found  that  40.8 
percent  of  pediatricians  failed  to  diagnose 


See  Chapter  IX. 


addiction  when  presented  with  a  classic 
description  of  an  adolescent  patient  with 
symptoms  of  addiction  involving  drugs  (other 
than  nicotine  or  alcohol).51  However,  another 
study  found  that,  among  adolescent  patients 
diagnosed  with  addiction,  primary  care 
physicians  recommended  some  type  of  follow- 
up1  for  94.7  percent  of  the  patients.52  A  study  of 
adolescents  admitted  to  an  inpatient  psychiatric 
unit1  found  that  one-third  met  clinical  criteria  for 
addiction,  but  outpatient  clinicians  had  not 
identified  addiction  in  any  of  these  patients 
before  admission  to  the  inpatient  unit.53 

Other  research  found  that  only  1 3  percent  of 
patients  who  received  an  addiction-related 
diagnosis  while  visiting  an  ED  received  follow- 
up  addiction  treatment  services  within  two 
weeks  of  the  visit.5  More  than  200  patients  in 
the  study  had  another  ED  visit  within  two 
months  of  their  initial  ED  visit,54  suggesting  that 
hospitals  do  not  appropriately  address  patients' 
addiction  or  provide  them  with  referrals  to 
treatment.** 55  A  study  of  ED  patients  admitted 
with  cocaine-related  chest  pain  found  that  three- 
quarters  (74.7  percent)  had  not  received  any 
treatment  three  months  after  discharge.56 

Detoxification  Frequently  is  Considered 
Treatment  Rather  Than  a  Precursor  to 
Treatment.  A  minority  of  patients  who 
participate  in  detoxification  programs  go  on  to 
receive  treatment,  despite  evidence  that 


'  Defined  in  this  study  as  any  plan  beyond  periodic 
screening,  including  notification  of  parents,  referral 
to  counseling,  return  visit  with  the  primary  care 
physician  or  noting  that  the  patient  already  was  in 
counseling  for  substance  use. 
*  Patients  were  admitted  to  the  unit  for  psychiatric 
conditions  other  than  addiction. 
§  The  primary  diagnosis  for  patients  included  in  the 
study  was  addiction  for  28  percent  of  the  sample, 
mental  health  issues  for  13  percent  of  the  sample  and 
medical  (non-psychiatric)  disorders  for  59  percent  of 
the  sample. 

**  Another  study  found  that  patients  with  unmet 
addiction  treatment  needs  are  nearly  twice  as  likely  to 
be  admitted  to  the  hospital  and  nearly  one-and-a-half 
times  as  likely  to  have  made  at  least  one  ED  visit  in 
the  past  year  compared  to  patients  without  unmet 
treatment  needs. 


-204- 


treatment  beyond  detoxification  typically  is  a 
medical  necessity.57  In  2008,*  only  12.6  percent 
of  discharges  from  detoxification  programs 
transferred  to  a  treatment  facility.  About  one  in 
10  (10.8  percent)  of  alcohol  detoxification 
discharges  were  transferred  to  a  treatment 
facility,  as  were  20.7  percent  of  marijuana 
detoxification  discharges,  13.6  percent  of  other 
illicit  drug  detoxification  discharges,'  18.2 
percent  of  prescription  drug  detoxification 
discharges  and  13.9  percent  of  multiple 
substance  detoxification  discharges.58  Another 
study  found  that  only  32.8  percent  of  Medicaid- 
enrolled  adult  patients  discharged  from 
detoxification  received  follow-up  care  within  30 
days  of  discharge.1 59 

Addiction  Treatment  Rarely  Addresses 
Smoking.  Although  recent  scientific  evidence 
underscores  the  unitary  nature  of  the  disease  of 
addiction  and  the  consequent  need  to  address 
addiction  involving  all  substances,60  many 
addiction  treatment  providers  continue  to 
address  addiction  involving  alcohol,  illicit  drugs 
and  controlled  prescription  drugs  while  largely 
ignoring  addiction  involving  nicotine.61 

Smoking  cessation  services  are  not  commonly 
implemented  in  addiction  treatment  settings62  or 
in  psychiatric  treatment  settings.63 

The  reluctance  to  provide  smoking  cessation 
services  to  patients  in  treatment  for  addiction 
involving  alcohol  or  other  drugs  stems  in  part 
from  an  unfounded  concern  that  it  might 
jeopardize  patients'  ability  to  abstain  from 
alcohol  or  other  drug  use.64  There  is  no 
evidence  that  quitting  smoking  interferes  with 


Most  recent  available  data. 
'  19.4  percent  of  opioid  (other  than  heroin) 
detoxification  discharges,  16.4  percent  of 
cocaine/crack  detoxification  discharges  and  12.4 
percent  of  heroin  detoxification  discharges 
transferred  to  a  treatment  facility. 
*  This  disparity  stems  in  part  from  financial 
constraints.  Some  insurance  plans  pay  only  for 
medical  detoxification  but  not  for  addiction  treatment 
including  psychosocial  and  pharmaceutical  therapies. 
Some  plans  that  do  cover  both  detoxification  and 
treatment  manage  them  separately,  making  continuity 
of  care  difficult. 


the  effectiveness  of  treatment  for  addiction 
involving  alcohol  or  other  drugs.65  In  fact, 
research  shows  improved  addiction  treatment 
outcomes  among  patients  who  receive  smoking 
cessation  services,  including  reduced  risk  of 
relapse  following  treatment  and  improved 
outcomes  for  co-occurring  addiction  involving 
alcohol.66  In  light  of  this  evidence,  some  states5 
are  banning  smoking  in  addiction  treatment 
facilities  and  requiring  that  smoking  cessation 
services  be  provided  to  patients.67  Making 
smoking  cessation  a  key  component  of  addiction 
treatment  programs  would  go  a  long  way  toward 
improving  treatment  outcomes  as  well  as  the 
long-term  health  of  patients  with  addiction.68 

One  study  found  that  fewer  than  half  (43 
percent)  of  addiction  treatment  programs  in  the 
United  States  offer  formal  smoking  cessation 
services;  no  data  are  available  on  the  extent  to 
which  nicotine  addiction  is  fully  integrated  into 
these  treatment  programs."  Among  those  that 
do  offer  cessation  services,  more  offer 
pharmaceutical  interventions  than  psychosocial 
interventions  (37  percent  vs.  18  percent).69 

Although  rates  of  smoking  among  adolescent 
addiction  treatment  patients  are  high  and 
effective  interventions  are  available,70  less  than 
half  (42.8  percent)  of  treatment  programs 
designed  specifically  for  adolescents  offer 
smoking  cessation  services;  13  percent  offer  a 
comprehensive  formal  program  with 
pharmaceutical  therapy,  15.3  percent  offer 
counseling  only  and  14.5  percent  offer 
pharmaceutical  therapy  only.71 

Less  than  20  percent  of  addiction  treatment 
providers  received  any  training  in  smoking- 
related  issues  in  the  past  year.72  This  is  despite 
the  fact  that  the  majority  (between  65  and  87 
percent)'1  of  patients  in  addiction  treatment 


5  NY,  NJ,  WA. 

CASA  Columbia's  survey  of  directors  of  addiction 
treatment  programs  in  New  York  State  found  that  the 
majority  (89.2  percent)  indicated  that  treatment  for 
addiction  involving  nicotine  is  offered  in  their 
addiction  treatment  programs. 
' r  Data  based  on  a  review  of  several  studies. 


-205- 


programs  smoke— a  rate  more  than  three  times 
that  in  the  general  population.73 

Pharmaceutical  Treatments  are 
Underutilized.  A  key  factor  in  integrating 
addiction  treatment  into  mainstream  medicine  is 
broader  implementation  of  pharmaceutical 
interventions,  when  indicated.74  Yet  providers 
of  addiction  treatment  vastly  underutilize 
evidence-based  pharmaceutical  therapies.75 

CAS  A  Columbia's  survey  of  directors  of 
addiction  treatment  programs  in  New  York  State 
found  that  less  than  half  (47.0  percent)  indicated 
that  pharmaceutical  treatments  are  offered  in 
their  addiction  treatment  programs.76 

A  national  longitudinal  survey  of  programs  that 
offer  addiction  services*  found  that  the 
percentage  of  programs  offering  nicotine 
replacement  therapy  (NRT)  decreased 
significantly  from  38.0  percent  during  2002- 
2004  to  33.8  percent  four  years  later.  Programs 
were  more  likely  to  continue  offering  NRT  if 
they  were  medically  oriented  (i.e.,  located  in  a 
hospital  setting  with  access  to  physicians).77 

Underutilization  of  pharmaceutical  treatments  is 
particularly  common  in  treatment  programs  that 
are  publicly  funded,  small,  not  located  in  a 
hospital,  not  accredited'  and  have  few  medical 
professionals-including  physicians  and  nurses— 
on  staff78  National  data  indicate  that  among 
privately-  and  publicly-funded  treatment 
programs,  approximately  half  have  adopted  at 
least  one  pharmaceutical  treatment  for 
addiction.1 79 


Including  privately-funded  treatment  organizations, 
publicly-funded  treatment  organizations  and 
therapeutic  communities. 

'  By  the  Joint  Commission  or  the  Commission  on 
Accreditation  of  Rehabilitation  Facilities  (CARF). 
(See  Chapter  IX  for  a  description  of  these  accrediting 
organizations.) 

*  Approximately  51  percent  of  privately- funded 
programs  and  25  percent  of  publicly-funded 
programs  adopted  buprenorphine  in  their  treatment  of 
addiction,  40  percent  of  private  programs  and  19 
percent  of  public  programs  adopted  acamprosate  or 
tablet  naltrexone,  30  percent  of  private  programs  and 
16  percent  of  public  programs  adopted  disulfiram  and 


The  limited  adoption  of  pharmaceutical 
treatments  for  addiction,  when  indicated,  is  due 
in  large  part  to  a  lack  of  qualified  medical  staff 
in  addiction  treatment  programs  to  prescribe  and 
monitor  medication  protocols.80  Thirty-eight 
percent  of  publicly-funded  programs  do  not  even 
have  access  to  a  prescribing  physician,  nor  do  23 
percent  of  privately-funded  programs.81 

Treatment  providers  seem  to  have  more  negative 
attitudes  toward  the  use  of  pharmaceutical 
therapies  relative  to  psychosocial  therapies.82 
Some  treatment  programs  see  pharmaceutical 
treatments  for  addiction,  such  as  the  use  of 
methadone  maintenance  treatment  for  addiction 
involving  opioids,  as  incompatible  with 
abstinence-based  treatment  approaches;83  there 
is  a  stigma  among  some  providers  attached  to 
the  use  of  pharmaceuticals  to  achieve  abstinence 
from  a  drug  to  which  the  patient  is  addicted. 
One  of  the  key  predictors  of  the  underutilization 
of  pharmaceutical  treatments  is  adherence  of 
treatment  providers  to  a  strong  12-step  ideology 
for  addiction  treatment.84 

CASA  Columbia's  survey  of  treatment  providers 
in  New  York  State  found  that  respondents  were 
more  likely  to  say  that  recreational  therapy/ 
leisure  skills  training  is  a  "very  important" 
intervention  for  a  treatment  facility  to  offer  to 
patients5  than  to  say  the  same  of  pharmaceutical 

**  85 

treatments. 

Addiction  treatment  medications  also  may  be 
underutilized  by  physicians  themselves  due  in 
part  to  insufficient  evidence  regarding  optimal 
dosages  of  certain  pharmaceutical  therapies, 
durations  of  use,  how  to  combine  the  use  of 
medications  with  counseling  and  the 


less  than  20  percent  of  private  programs  and  less  than 
10  percent  of  public  programs  adopted  injectable 
naltrexone  in  their  treatment  protocols. 
§  51.8  percent  of  program  directors,  54.7  percent  of 
staff  providers. 

28.0  percent  of  program  directors,  33.8  percent  of 
staff  providers  for  methadone  maintenance  treatment 
and  43.9  percent  of  program  directors,  45.7  percent 
of  staff  providers  for  other  medication  treatments  for 
addiction  such  as  buprenorphine,  disulfiram  or 
naltrexone. 


-206- 


generalizability  of  research-based  efficacy 
findings  to  different  patient  populations.86 

Although  one  study  found  that  each  additional 
physician  on  staff  in  a  treatment  program  was 
associated  with  a  doubling  of  the  odds  that  the 
program  would  adopt  the  use  of  pharmaceutical 
treatments  for  addiction,87  having  access  to  a 
staff  physician  does  not  guarantee  access  to  or 
use  of  pharmaceutical  treatments.88  One  study 
found  that  82  percent  of  publicly-funded 
addiction  treatment  programs  with  access  to  a 
physician  did  not  prescribe  any  treatment 
medications  for  addiction  involving  alcohol;  the 
same  is  true  of  4 1  percent  of  privately-funded 
treatment  programs  with  access  to  a  prescribing 
physician.89 

The  treatment  of  addiction  involving  opioids 
presents  one  of  the  most  glaring  examples  of  the 
underutilization  of  clinically-effective  and  cost- 
effective  pharmaceutical  treatments  for 
addiction.91  Buprenorphine  is  a  pharmaceutical 
treatment  for  addiction  involving  opioids  that, 
despite  a  rich  body  of  evidence  demonstrating  its 
efficacy,  safety92  and  cost  effectiveness,93  is 
significantly  underutilized  in  practice.94  The 
majority  (86  percent)  of  addiction  counselors 
report  not  being  aware  of  the  effectiveness  of 
buprenorphine.95 


We  're  seeing  less  interest  [in  prescribing 
buprenorphine]  than  we  expected,  especially 
among  primary  care  physicians.96 

-Robert  Lubran,  MPA 
Director 

Division  of  Pharmacological  Therapies 
Center  for  Substance  Abuse  Treatment  (CSAT) 

SAMHSA 


Specific  additional  obstacles  to  the  widespread 
use  of  buprenorphine  by  physicians  include  cost, 
lack  of  insurance  coverage  and  availability 
problems  due  to  pharmacies  not  stocking  the 
medication.97 

Physicians'  biases  against  patients  with 
addiction  may  contribute  to  the  limited  adoption 
of  pharmaceutical  treatments  as  well.98  Survey 
results  from  a  random  sample  of  internal 


medicine,  family  medicine,  psychiatry  and  pain 
management  physicians  in  Maryland  found  that 
only  36  percent  of  respondents  were  willing  to 
prescribe  buprenorphine  to  an  established  patient 
and  only  28  percent  were  willing  to  prescribe  the 
medication  to  a  new  patient.  Seventeen  percent 
of  physicians  unwilling  to  prescribe  the 
medication  said  that  addiction  involving  opioids 
is  best  described  as  a  habit  rather  than  an  illness; 
none  of  the  physicians  willing  to  prescribe  the 
medication  agreed  with  this  statement.  Half  of 
the  Maryland  doctors  who  were  not  willing  to 
prescribe  buprenorphine  reported  that  they 
believe  that  treatment  for  addiction  involving 
opioids  is  beyond  the  scope  of  practice  of  office- 
based  physicians  and  46  percent  reported  not 
wanting  patients  with  addiction  involving 
opioids  in  their  clinics.99 


The  reason  I  am  not  interested  [in  prescribing 
buprenorphine]  is  /  see  this  as  an  opportunity  for 
drug  users  who  are  by  class  the  most  lying, 
scheming,  dishonest  group  of  patients.  They  need 
hard-based,  no-nonsense  treatment  programs.  I 
can't  stand  their  manipulative  behavior.90 

Anonymous  Physician 


The  fact  that  buprenorphine  can  be  prescribed  in 
physicians'  offices  for  at-home  use  was  heralded 
as  a  step  forward  in  the  treatment  of  addiction 
involving  opioids.  Addiction  professionals 
anticipated  the  medication's  potential  to  help 
addiction  treatment  become  a  more  central 
component  of  medical  practice.101  However, 
these  hopes  have  not  come  to  fruition.102 


There  is  no  other  comparable  example  in 
medicine  where  you  have  evidence-based 
treatments  that  are  not  available. 100 

-Shelly  Greenfield,  MD,  MPH 
Chief  Academic  Officer,  McLean  Hospital 
Professor  of  Psychiatry, 
Harvard  Medical  School 
Director,  Clinical  and  Health  Services  Research 
and  Education  Division  of  Alcohol 
and  Drug  Abuse,  McLean  Hospital 


-207- 


Nutrition  and  Exercise  Are  Not  Integrated 
into  Addiction  Treatment.  Although  good 
nutrition  and  exercise  are  important  components 
of  comprehensive  addiction  treatment*  103- 
particularly  in  light  of  recent  research 
underscoring  common  brain  circuitry  involved 
in  substance-related  addiction  and  obesity104~the 
extent  to  which  nutrition  and  exercise  are 
incorporated  into  addiction  treatment  has  not 
been  examined.  One  small  study'  found  that  56 
percent  of  dietitians  and  nutrition  program 
managers  working  in  addiction  treatment 
facilities  reported  that  their  facilities  offered 
nutrition-related  addiction  education  in  group 
settings  to  only  about  half  of  their  patients. 
Fifty-six  percent  of  respondents  reported 
offering  nutrition-related  addiction  education  in 
individual  settings  to  an  average  of  1 8  percent  of 
their  patients.105 

Formal  Treatment  Is  Conflated  with  Support 

Services.  The  overwhelming  salience  and 
considerable  evidence-although  largely 
anecdotal-of  the  benefits  of  mutual  support 
programs  like  Alcoholics  Anonymous  (AA),  for 
example,  have  led  many  people  to  conflate  such 
support  services  with  actual  addiction  treatment 
rather  than  to  recognize  them  as  highly  useful 
systems  of  support  that  should  accompany  or 
follow  evidence-based  clinical  treatment.  * 106 
Mutual  support  programs  are  facilitated  by 
members  whose  main  credential  is  that  they 
themselves  have  experienced  an  addictive 
disorder  and  have  learned  to  manage  it.  Such 
support,  however,  is  quite  different  than 
treatment  for  a  medical  condition.5  107  Few 
would  argue  that  any  other  disease  be  treated 


See  Chapter  V. 
'  Using  a  non-randomized  sample. 
*  There  are  some  exceptions  where,  depending  on  the 
severity  of  disease  symptoms  and  the  patient's  health 
status  and  degree  of  social  support,  certain  patients 
are  able  to  manage  their  addiction  with  support 
services  only  or  no  interventions  at  all.  In  addition,  it 
should  be  noted  that  Twelve-Step  Facilitation, 
discussed  in  Chapter  V,  is  a  formalization  and 
professionalization  of  the  12-step  mutual  support 
model  and  has  been  deemed  an  evidence-based 
treatment  for  addiction. 

§  AA  openly  recognizes  addiction  as  a  medical 
condition. 


solely  via  support  groups  composed  of  those 
who  themselves  have  had  the  condition. 

Tailored  Treatment  Services 

Whereas  research  clearly  indicates  that  to  be 
effective  interventions  should  be  tailored  not 
only  to  the  stage  and  severity  of  a  patient's 
illness  but  also  to  a  patient's  co-occurring 
conditions  and  other  personal  characteristics  and 
life  circumstances  that  might  affect  treatment 
outcome,  most  health  professionals  and 
addiction  treatment  programs  follow  a  one- size- 
fits-all  approach  to  treatment. 

Disease  Severity  Rarely  is  Assessed  and 
Interventions  Rarely  are  Tailored  to  Stage 
and  Severity  of  Disease.  It  is  standard 
recommended  medical  practice  to  assess  the 
stage  and  severity  of  a  patient's  disease  in  order 
to  develop  an  effective  treatment  plan  and  tailor 
treatment  accordingly.108  Assessment  of  disease 
severity  is  an  essential  part  of  addiction 
treatment  as  well.109  One  of  the  most  widely- 
used  tools,  both  in  research  and  clinical  practice, 
for  assessing  the  severity  of  addiction  is  the 
Addiction  Severity  Index,  although  even  this 
instrument  fails  to  address  addiction  involving 
nicotine.110  Yet,  the  extent  to  which  treatment 
providers  tailor  treatment  protocols  based  on  the 
findings  of  such  assessments  is  limited.111 
Instead,  addiction  treatment  programs  typically 
utilize  a  non-tailored  approach  to  patient  care.112 

Having  patients  pass  through  a  rigid,  time- 
limited  treatment  program  that  assumes 
uniformity  in  disease  symptoms  and  severity 
simply  burdens  patients  with  unnecessarily 
extensive  interventions  or  with  interventions  that 
are  too  brief  or  superficial  to  have  a  significant 
impact  on  their  symptoms.  Yet  the  standard 
treatment  for  addiction  is  non-intensive 
outpatient  treatment,113  often  without  adequate 
professional  follow-up  care  and  disease 
management.  Even  residential  treatment 
typically  is  limited  to  a  28-day  stay  in  a  program 
despite  little  evidence  that  the  condition  remits 
after  such  a  brief  period  of  time.114  Given  this 
standard  approach  to  treatment  that  focuses 
primarily  on  acute  care  only,  it  is  little  wonder 
that  relapse  is  so  common  and  that  addiction 


-208- 


continues  to  be  seen  as  an  intractable  condition 
largely  resistant  to  treatment. 


We  are  treating  these  folks  with  severe  and 
persistent  addiction  with  a  time  limited-treatment 
of  three  or  four  weeks,  maybe  six  or  eight,  maybe 
at  the  most  three  months,  if  you  want  to  include 
what's  called  aftercare.  Now,  why  would  we  think 
that  treating  a  chronic  disorder  for  a  few  weeks 
would  lead  to  improvement  10  years  later  or  five 
years  later  or  even  a  year  later?  It  doesn  't  make 
any  sense.115 

-Mark  Willenbring,  MD 
Director,  Division  of  Treatment  and  Recovery 
National  Institute  on  Alcohol 
Abuse  and  Alcoholism 
(currently,  Associate  Professor  of  Psychiatry, 
University  of  Minnesota) 


Interventions  Do  Not  Adequately  Address 
Co-occurring  Conditions.  In  standard  medical 
practice,  it  is  recommended  that  health 
professionals  assess  the  presence  of  co-occurring 
conditions  in  order  to  develop  an  effective 
treatment  plan  and  tailor  treatment 
accordingly.116  Although  such  assessments  are 
critical  in  addiction  treatment  given  the  very 
high  rate  of  co-occurring  conditions  in  people 
with  addiction,  treatment  programs  frequently 
do  not  address  co-occurring  health  conditions  or 
do  so  in  a  suboptimal  way.117 

Implementing  a  one-size-fits-all  approach  to 
treatment  based  solely  on  a  clinical  diagnosis 
without  consideration  of  co-occurring  health 
conditions  often  amounts  to  a  waste  of  time  and 
resources.  CASA  Columbia's  survey  of 
directors  of  addiction  treatment  programs  in 
New  York  State  found  that  less  than  half  (48.2 
percent)  of  the  program  directors  indicated  that 
treatment  for  co-occurring  mental  and  physical 
health  disorders  is  offered  in  their  programs.118 

A  recent  study  of  patients  in  residential 
treatment  for  addiction  who  had  co-occurring 
mental  health  conditions  underscores  the 
importance  of  tailoring  treatment  to  the  needs  of 
the  patient  population.  In  this  study,  those  with 
co-occurring  mental  health  conditions  reported 
less  satisfaction  with  treatment,  saw  fewer 


benefits  to  stopping  their  substance  use,  had  less 
belief  in  their  efforts  to  control  their  substance 
use  to  maintain  abstinence  and  were  less  likely 
to  employ  positive  coping  skills  than  patients 
with  addiction  who  did  not  have  co-occurring 
mental  health  conditions.119 


/  lost  my  son  to  addiction  and  ultimately  suicide. 
From  the  time  I  knew  he  had  a  problem  until  the 
day  he  died,  I  tried  everything  at  my  disposal  to 
help  him  get  quality  care.  He  went  to  eight 
different  programs  and  they  all  had  a  different 
approach;  many  offered  conflicting  advice. 
Only  four  of  them  looked  at  Brian  as  a  whole 
person;  the  other  four  only  looked  at  his 
addiction.  Only  five  included  a  comprehensive 
medical  assessment;  in  fact,  only  three  even  had 
a  full-time  doctor  on  the  premises.  And 
although  they  each  viewed  his  condition  as  a 
chronic  disease  requiring  effective  aftercare  and 
long  term  management,  none  of  them  had  an 
effective  recommendation  for  this,  nor  any 
follow  up  from  that  program.  In  a  letter  to  me 
during  one  of  his  stays  in  a  residential  program, 
he  offered  the  insight  that  much  of  his  previous 
rounds  of  treatment  had  addressed  his  addiction 
in  isolation— as  if  it  were  unrelated  to  any 
underlying  emotional  problems.  In  the  last 
weeks  of  his  life,  Brian  was  suffering  from 
severe  depression.  On  the  day  before  he  died, 
his  aftercare  program  made  the  decision, 
without  consulting  Brian 's  therapist,  or  his 
parents,  to  terminate  their  relationship  with  him. 
At  the  time  Brian  most  needed  help,  he  was  left 
alone.  And  so  was  1. 120 

-Gary  Mendell,  father 
Lost  his  son  Brian,  age  25, 
to  addiction  and  suicide 


Although  people  with  mental  illness  smoke  at 
significantly  higher  rates  than  the  general 
population,  smoking  cessation  services  rarely 
are  provided  by  mental  health  treatment 
professionals.121  Generally  psychiatrists  are  less 
likely  than  family  physicians  to  inquire  about 
smoking,  offer  advice  on  quitting  or  assess 
patients'  willingness  to  quit.122  Yet,  because 
individuals  with  severe  mental  illness  interact 
with  psychiatrists  to  a  greater  extent  than  with 
primary  care  physicians  (who  typically  are  the 
main  referral  source  or  provider  of  smoking 
cessation  interventions),  patients  in  mental 


-209- 


health  settings  who  smoke  may  be  even  less 
likely  to  receive  the  smoking  cessation  services 
they  need.123  Psychiatrists  may  eschew  smoking 
cessation  interventions  because  they  believe 
"patients  have  more  immediate  problems  to 
address;"  some  medical  and  other  health 
professionals  also  may  be  reluctant  to  encourage 
smoking  cessation  because  they  feel  it  "gives 
patients  with  psychiatric  illnesses  comfort  while 
dealing  with  their  mental  illness  symptoms."124 
Contrary  to  these  beliefs,  research  shows  that 
smokers  with  mental  health  conditions  are  as 
motivated  as  those  in  the  general  population  to 
quit  smoking125  and  one  study  showed  that  the 
majority  (79  percent)  of  mentally  ill  smokers 
want  to  quit.126 

Interventions  Rarely  are  Tailored  to  Patient 
Characteristics  that  Might  Affect  Treatment 
Outcomes.  Not  taking  into  account  a  patient's 
age,  gender,  race/ethnicity,  socioeconomic  status 
or  system  of  personal  supports  in  designing  a 
treatment  intervention  can  compromise 
otherwise  effective  treatment  plans. 
Chapter  VI  of  this  report  outlines  specific 
treatment  needs  of  special  populations  and 
Chapter  VII  shows  the  gaps  in  needed  treatment 
for  some  of  these  groups.  While  the  baseline 
level  of  addiction-related  services  offered  to  the 
general  population  is  inadequate,  the  deficiency 
in  tailored  services  offered  to  populations  with 
special  treatment  needs  is  even  more  glaring.127 

Chronic  Disease  Management 

For  many  individuals,  addiction  manifests  as  a 
chronic  disease,  requiring  disease  and  symptom 
management  over  the  long  term.128  In  recent 
years,  there  has  been  growing  recognition  of  the 
importance  of  comprehensive  disease 
management  in  the  treatment  of  chronic  health 
conditions  for  which  there  is  no  known  cure, 
where  relapse  episodes  are  considered  an 
expected  part  of  the  disease  course  and  where 
long-term  symptom  management  is  considered 
routine  care.  While  this  approach  increasingly 
has  been  adopted  for  diseases  such  as 

1 29  1 30  131 

diabetes,     hypertension    and  asthma, 
addiction  treatment  largely  remains  stuck  in  the 
acute-care  model.132 


Patients  with  addiction,  regardless  of  the  stage 
and  severity  of  their  disease,  typically  receive  a 
diagnosis  followed  by  a  swift  course  of 
treatment  administered  by  individuals  without 
any  medical  training  and  then  minimal  to  no 
follow-up  care.133  In  contrast  to  other  chronic 
diseases,  positive  results  from  a  short-term 
intervention  or  treatment  for  addiction  are 
expected  to  endure  indefinitely  and  relapse 
commonly  is  viewed  as  a  sign  of  treatment 
failure,  at  best,  and  as  evidence  of  a  deficit  in 
patients'  willpower  or  dedication  to  managing 
their  condition,  at  worst,  rather  than  as  a  result 
of  inadequate  treatment  or  follow-up  care.134 

Evidence  of  the  acute  care  approach  to  addiction 
treatment  is  that  current  Medicare  and  Medicaid 
regulations  indicate  that  hospital  readmissions 
for  patients  with  addiction  involving  alcohol  are 
not  to  be  treated  as  extensions  of  the  original 
treatment  but  rather  as  a  new  admission  to  treat 
the  same  condition.  Readmissions  can  be  seen 
as  evidence  that  treatment  is  not  working  and 
typically  are  not  covered  unless  a  physician  can 
document  a  change  in  the  patient's  physical, 
emotional  or  social  condition  that  makes  it 
reasonable  to  expect  that  additional  treatment 
would  improve  the  patient's  condition,  or 
documents  why  the  initial  treatment  was 
insufficient.135  Given  that  addiction  often  is  a 
chronic  disease  and  that  relapse  is  possible, 
limitations  on  hospital  readmissions  may  reduce 
access  to  needed  care  and  reflect  a  fundamental 
mischaracterization  of  the  disease  and  its 
expected  course  of  treatment. 


-210- 


Examples  of  the  Evidence-Practice  Gap  in  Addiction  Treatment  throughout  History 

The  use  of  addiction  treatments  that  are  not  grounded  in  science  has  a  long  history.  While  most  of  these  approaches  have 
been  discredited  with  time,  some  have  proven  to  be  prescient  in  their  foreshadowing  of  current  treatment  approaches,  both 
those  that  are  evidence  based  and  those  that  continue  to  profit  from  claims  about  being  able  to  treat  or  even  cure  addiction  in 
manners  that  largely  are  not  based  on  scientific  evidence. 

For  example,  in  the  late  1700s,  Dr.  Benjamin  Rush,  the  "father  of  American  psychiatry,"  was  the  first  American  doctor  to  say 
that  "habitual  drunkenness  should  be  regarded  not  as  a  bad  habit  but  as  a  disease"136  that  should  be  treated.137  In  the  late  19th 
century,  medically -based  addiction  treatment  mostly  involved  trying  to  cure  individuals  of  their  addiction,  often  with  the  use 
of  other  addictive  substances.138 

By  1910,  private  sanitariums  in  the  United  States  offered  specialized  treatment  for  addicted  individuals— but  only  for  those 
who  could  afford  the  expense.  Similar  to  today,  many  of  the  "treatment  experts"  opening  facilities  were  savvy  businessmen 
or  enterprising  physicians,  including  Harvey  Kellogg  (later  of  cereal  fame)  and  Dr.  Leslie  E.  Keeley.  Between  1892  and 
1893,  almost  15,000  people  with  addiction  were  treated  at  the  famous,  yet  controversial  Keeley  Institutes.139  Keeley's 
treatment  for  addiction  involved  bichloride  of  gold  remedies,  a  substance  purportedly  containing  gold  that  would  cure 
addiction  involving  alcohol  and  opioids.  The  use  of  bichloride  of  gold  became  highly  controversial  and  was  opposed  by  the 
American  Medical  Association  (AMA).  After  the  death  of  Dr.  Keeley  in  1900,  the  popularity  and  ultimately,  the  existence  of 
his  institutes  waned.140 

Although  Keeley's  treatments  were  later  discredited,  his  position  that  addiction  was  decidedly  a  disease  rather  than  a 
religious  or  moral  failing  was  ahead  of  its  time.  His  use  of  "shot  treatments"  or  hypodermic  treatments  that  induced  vomiting 
was  a  precursor  to  later  aversion  therapies  and  his  introduction  of  clubs  for  addicted  individuals  to  receive  social  support  to 
maintain  sobriety  was  a  precursor  to  the  mutual  support  programs  that  remain  prominent  today.  His  focus  on  helping  people 
quit  smoking  in  the  1920s  was  prescient  in  its  characterization  of  nicotine  as  a  harmful  and  addicting  drug.141 

Addiction  treatment  tactics  that  are  based  more  on  the  personal  charisma  of  the  founders,  catchy  phrases  and  simplistic 
approaches  than  on  the  science  of  what  works  in  addiction  continue  to  proliferate  and  show  no  sign  of  waning.  A  simple 
Google  search  produces  an  abundance  of  "rehabilitation"  approaches  and  facilities  with  slogans  such  as:  Learn  how  to  heal 
the  underlying  causes  of  dependency— and  be  free  of  addiction  forever!142  A  recent  study  examining  treatments  that  a  panel 
of  experts  believes  qualifies  as  quackery  in  addiction  treatment  found  such  treatments  as  electrical  stimulation  of  the  head, 
past-life  therapy,  electric  shock  therapy,  psychedelic  medication  and  neuro-linguistic  programming  to  be  "certainly 
discredited."143  Nevertheless,  unsubstantiated  interventions  continue  to  be  used  to  this  day,  many  of  which  prey  upon  the 
desperation  of  addicted  individuals  and  their  families. 

In  the  late  1930s  and  early  1940s,  many  hospitals  would  not  admit  patients  for  the  treatment  of  addiction  involving  alcohol, 
so  lay  approaches  became  an  important  option.144  Alcoholics  Anonymous  (AA),  founded  in  1935,  was  premised  on 
laypersons  addicted  to  alcohol  helping  one  another  overcome  their  addiction  and  related  problems. 145  While  the  mutual 
support/self-help  approach  maintained  the  perspective  of  addiction  as  a  disease— formalized  in  the  development  of  the 
principles  underlying  the  Minnesota  Model  in  the  1950s— the  "rehabilitative  model"  of  treatment  was  seen  as  distinct  from 
"the  medical  model."  Standard  medical  interventions  that  normally  would  be  applied  to  diseases  were  not  a  significant  part 
of  the  treatment,  nor  were  medical  or  other  health  professionals  called  upon  to  play  key  roles  in  treating  the  disease.146  This 
model  remains  the  dominant  approach  to  addressing  addiction  in  the  United  States.  Yet,  its  limitations  and  failure  to  address 
addiction  the  way  other  diseases  are  addressed  have  led  to  a  call  to  integrate  addiction  treatment  into  mainstream  medical 
care. 


Based  on  the  composite  opinions  of  a  panel  of  75  experts  regarding  65  addiction  treatments  which  they  rated  on  a 
continuum  from  "not  at  all  discredited"  to  "certainly  discredited." 


-211- 


Barriers  to  Closing  the  Evidence- 
Practice  Gap 

America's  approach  to  addressing  risky 
substance  use  and  providing  addiction  treatment 
has  evolved  outside  of  the  mainstream  public 
health  and  medical  systems.*  147  As  a  result: 

•  Most  primary  providers  of  intervention  and 
treatment  for  risky  substance  use  and 
addiction  do  not  have  the  requisite  training 
or  qualifications  to  implement  the  existing 
range  of  evidence-based  practices  and  face 
many  organizational  and  structural  barriers 
to  providing  services; 

•  Most  health  professionals  do  not  implement 
evidence-based  addiction  care  practices; 

•  Performance  and  outcome  measures  that 
should  be  a  routine  part  of  quality  assurance 
in  mainstream  medicine  are  limited  and 
rarely  implemented  in  addiction  treatment; 

•  The  pharmaceutical  industry  lacks  the 
incentive  to  develop  new  and  effective 
pharmaceutical  interventions  for  addiction 
treatment;  and 

•  Insurance  coverage  for  evidence-based 
intervention,  treatment  and  disease 
management  is  inadequate. 

Because  of  the  vast  chasm  between  the  health 
care  system  and  approaches  to  preventing  risky 
substance  use  or  treating  addiction,  medical 
professionals  fail  to  address  risky  substance  use 
or  addiction  or  take  responsibility  for 
intervention  or  treatment,  risky  substance  use  is 
addressed  primarily  in  terms  of  its  consequences 
and  addiction  treatment  providers  are  not  held  to 
the  same  standards  as  providers  of  mainstream 
medical  care. 


See  Chapter  IX  for  an  in-depth  discussion  of  the 
education  and  training  requirements  for  those 
providing  services  for  risky  substance  use  and 
addiction. 


The  lack  of  integration  of  screening  and 
intervention  and  addiction  treatment  into 
mainstream  health  care  has  led  to  many  missed 
opportunities  to  help  patients  who  engage  in 
risky  substance  use  or  who  have  addiction  and 
has  contributed  to  the  high  rates  of  relapse  and 
enormous  health  and  social  consequences 
associated  with  risky  use  and  addiction. 


The  Addiction  Treatment  Workforce  is  Not 
Qualified  to  Implement  Evidence-Based 
Practices 

For  most  illnesses,  the  preponderance  of 
treatment  interventions,  including  coordination 
of  services,  occurs  within  mainstream  medicine 
and  is  provided  and  managed  by  trained  medical 
professionals.  Other  highly-trained  and 
credentialed  health  professionals  may  be  part  of 
a  team  of  providers  working  with  a  physician. 
Motivated  and  experienced  non-professionals 
may  serve  additional  vital  functions-such  as 
providing  social  support  to  encourage  adherence 
to  a  treatment  plan  and  help  patients  maintain 
important  lifestyle  changes  that  can  reduce  the 
risk  of  relapse-but  their  roles  and  services  do 
not  supersede  or  replace  those  of  the  medical 
team. 

In  contrast,  the  majority  of  care  for  individuals 
with  addiction  is  provided  by  people  without  any 
medical  training  at  all  and  rarely  is  supervised 
by  medical  professionals.  Physicians  and  other 
medical  professionals  typically  are  absent  from 
or  on  the  periphery  of  the  treatment  process, 
occasionally  being  called  in  to  provide  a 
prescription  or  medically  monitor  a 
detoxification  protocol. 


One  of  the  fundamental  barriers  to  providing 
effective  treatment  is  the  fact  that  addiction  is 
not  integrated  into  medical  practice.  And  a  lot 
of  medical  people  like  and  want  it  that  way;  they 
do  not  want  to  deal  with  addiction;  they  do  not 
like  to  deal  with  the  people  and  they  do  not  feel 
effective  addressing  the  problem. 148 

—Keith  Humphreys,  PhD 
Professor 
Stanford  Medical  School 


-212- 


Addiction  treatment  services  primarily  are 
provided  through  community-based  treatment 
programs  that  were  established  in  the  1970s  and 
1980s  before  the  medical  model  gained  support 
and  changes  in  the  financial  structure  led  to 
increasing  demands  for  accountability  and 
efficiency.149  The  treatment  provider  workforce, 
although  frequently  highly  dedicated,  is 
composed  primarily  of  certified  alcoholism  and 
substance  abuse  counselors  (CASACs)— a 
profession  for  which  a  college  degree  typically 
is  not  required  and  in  which  counselors  receive 
limited  on-the-job  training  in  evidence-based 
practices 


150 


The  result  is  that  much  of  the  current  treatment 
provider  workforce  is  not  equipped  to  provide 
consistent  evidence-based  treatment,  including 
administering  and  monitoring  medication 
protocols,  implementing  complex  psychosocial 
interventions,  addressing  co-occurring  health 
conditions  or  responding  to  medical 
problems  that  may  arise  among 
individuals  undergoing  addiction 
treatment.151 


providers)  said  substance  abuse  counselors 
(CASACs);  16.3  percent  of  directors  and  17.8 
percent  of  staff  providers  said  social  workers, 
7.5  percent  of  directors  and  6.7  percent  of  staff 
providers  said  psychologists  and  only  1.3 
percent  of  directors  and  1.5  percent  of  staff 
providers  said  physicians.153 

Only  9.9  percent  of  program  directors  and  13.7 
percent  of  staff  providers  indicated  that  a 
medical  degree  is  a  "very  important" 
qualification  for  treatment  providers  to  have;  3.7 
percent  of  directors  and  6.5  percent  of  staff 
providers  thought  that  way  about  a  doctoral 
degree.  A  quarter  (24. 1  percent  of  directors  and 
26. 1  percent  of  staff  providers)  felt  that  a 
master's  degree  was  a  very  important 
qualification,  and  about  a  quarter  (26.8  percent 
of  directors  and  27.3  percent  of  staff  providers) 
felt  that  way  about  a  college/bachelor's 
degree.154  (Figure  10.A) 


CASA  Columbia's  survey  of  addiction 
treatment  providers  in  New  York  State 
provides  a  case  in  point.  It  found  that 
37.2  percent  of  staff  providers  do  not 
have  a  bachelor's  degree'  and  only 
67.5  percent  of  program  directors  and 
35.0  percent  of  staff  providers  have  a 
graduate  degree  of  any  type.152 

Further,  most  treatment  providers  see 
the  current  state  of  affairs  with  regard 
to  the  staffing  of  treatment  programs  as 
reasonable.  When  asked  which  type  of 
professional  they  think  is  best  qualified  to 
provide  addiction  treatment  services,  nearly 
three  quarters  of  respondents  to  CASA 
Columbia's  New  York  survey  (71.3  percent 
program  directors  and  72.6  percent  of  staff 


Figure  10.A 

New  York  State  Addiction  Treatment  Providers'  Beliefs 
about  the  Importance  of  the  Following  Provider 
Educational  Qualifications* 


26.8  27.3 


24.1 


26.1 


9.9 


13.7 


3.7 


6.5 


•  Director 
i  Staff 


College/Bachelor's  Master's  Degree    Medical  Degree    Doctoral  Degree 
Degree 

*  Among  those  who  responded  that  the  educational  qualification  is  "very 
important". 

Source:  Casa  Columbia  Survey  of  New  York  State  Addiction  Treatment 
Providers,  2009. 


of 


In  contrast,  the  majority  of  treatment  providers 
in  CASA  Columbia's  survey  (61.4  percent  of 
program  directors  and  76.3  percent  of  staff 
providers)  thought  that  personal  experience  with 
addiction  is  an  important  qualification  for 


See  Chapter  IX  for  specific  credentialing 
requirements. 

29.9  percent  had  some  college  or  an  associate's 
degree,  6.6  percent  had  only  a  high  school  degree  or 
GED  and  0.7  percent  did  not  complete  high  school  or 
have  a  GED. 


-213- 


addiction  treatment  providers  to  have. 

CAS  A  Columbia's  survey  also  found  that  only 
11.3  percent  of  program  directors  and  8.1 
percent  of  staff  providers  believe  that  the 
addiction  treatment  system  "should  be  integrated 
into  the  medical  system  such  that  addiction  is 
treated  as  a  health  condition  by  health  care 
professionals."  Two-thirds  of  directors  (66.3 
percent)  and  60.3  percent  of  staff  providers, 
however,  say  that  the  addiction  treatment  system 
"should  be  two-tiered  with  health  care 
professionals  providing  psychotherapeutic  and 
pharmacological  interventions  and  individuals 
with  histories  of  addiction  (in  recovery) 
providing  recovery  support  services."  Fewer 
directors  (7.5  percent)  but  more  staff  providers 
(21.3  percent)  indicated  that  "the  system  should 
revolve  around  a  recovery  support  model  with 
self-help/mutual  support  programs  as  the  main 
intervention."  Fifteen  percent  of  directors  and 
10.3  percent  of  staff  providers  think  that  nothing 
about  the  system  should  change.156 

Despite  this  variability  in  perceptions  regarding 
what  the  treatment  system  should  look  like, 
there  is  general  agreement  that  the  current 
system  is  riddled  with  organizational  and 
structural  problems  that  impede  the  delivery  of 
quality  care,  including  inadequate  financial 
resources,  high  staff  turnover  and  restricted 
professional  advancement.157  While  limited 
education  and  training  of  most  providers  and  a 
treatment  culture  largely  steeped  in  the  self-help 
model  stand  in  the  way  of  adopting  new, 
science-based  practices,158  organizational  and 
structural  problems  within  the  current  treatment 
system  compound  these  limitations  and  further 
prevent  the  delivery  of  evidence-based  care.159 

CASA  Columbia's  survey  of  treatment  providers 
in  New  York  State  found  that  respondents  were 
most  likely  to  cite  a  high  volume  of  paperwork 


Among  program  directors,  28.9  percent  said 
personal  experience  is  slightly  important,  25.3 
percent  said  it  is  moderately  important  and  7.2 
percent  said  it  is  very  important.  Among  staff 
providers,  36.0  percent  said  personal  experience  is 
slightly  important,  21.6  percent  said  it  is  moderately 
important  and  18.7  percent  said  it  is  very  important. 


(reporting  requirements  that  take  up  too  much 
time  and  resources),  insufficient  salaries  to 
attract  and  retain  high-quality  staff,  insufficient 
program  funding  and  insufficient  insurance 
coverage  for  patients  as  barriers  that  "very 
much"  stand  in  the  way  of  providers'  ability  to 
provide  effective  services  to  people  in  need  of 
addiction  treatment— reflecting  both  frustration 
with  organizational  barriers  to  quality  care  and  a 
non-medical  approach  to  treatment.  An 
insufficient  number  of  trained  medical-level 
(MD/DO)  professionals  was  least  likely  to  be 
named  by  providers  as  a  barrier  that  "very 
much"  stands  in  the  way  of  providing  effective 
treatment  services.160  (Table  10.1) 


Table  10.1 

New  York  State  Addiction  Treatment  Providers'  Opinions 
of  Barriers  that  "Very  Much"  Stand  in  the  Way  of 
Providing  Effective  Addiction  Services 


Program 

Staff 

Directors 

Providers 

High  volume  of  paperwork/reporting 

requirements 

76.8 

72.7 

Insufficient  salaries  to  attract  and  retain 

74.7 

69.8 

high-quality  staff 

Insufficient  program  funding 

62.2 

63.3 

Insufficient  insurance  coverage 

60.2 

61.6 

Insufficient  number  of  appropriately  trained 

staff  with  the  qualifications  necessary  to 
provide  treatment  for  co-morbid  conditions 

56.1 

37.4 

Insufficient  number  of  trained  master's- 

28.0 

20.9 

level  professionals 

Insufficient  number  of  appropriately  trained 

staff  with  the  qualifications  necessary  to 
provide  pharmacological  therapies 

26.5 

19.7 

Limited  motivation  among  staff  members  to 

be  knowledgeable  about  evidence-based 

24.1 

19.7 

best  practices 

Insufficient  professional  standards  related 
to  knowledge  and  clinical  skills  for 

20.5 

21.7 

individuals  providing  addiction  treatment 

Insufficient  federal-  or  state-level  education 

and  training  requirements  for  individuals 

18.1 

23.2 

providing  addiction  treatment 

Insufficient  access  to  information  about 

13.3 

15.9 

best  practices 

Insufficient  number  of  trained  medical-level 

12.3 

13.0 

(MD/DO)  professionals 

Source:  CASA  Columbia  Survey  of  New  York  State  Addiction 
Treatment  Providers,  2009.  


-214- 


Most  Addiction  Treatment  Providers  Do  Not 
Adopt  Evidence-Based  Practices.*  Many 
addiction  treatment  providers  address  addiction 
in  ways  that  have  not  been  evaluated  or  proven 
effective.  While  this  is  due  in  part  to  the 
inadequate  education  and  training  of  treatment 
providers  in  evidence-based  practices,161  the 
larger  issue  is  the  significant  mismatch  between 
the  qualifications  that  are  necessary  for 
implementing  many  evidence-based  practices 
and  the  qualifications  that  the  majority  of  the 
treatment  workforce  currently  possesses.162 
Because  most  treatment  providers  are  not 
adequately  trained,  they  are  not  capable  of 
performing  health  assessments,  prescribing 
pharmaceutical  medications,  treating  co- 
occurring  health  conditions  or  managing  a 
chronic  disease,  each  of  which  is  an  essential 
evidence-based  addiction  treatment  practice.163 
Most  also  are  not  trained  in  the  scientific  method 
or  clinical  research,  further  impeding  their 
ability  to  integrate  clinical  research  findings  into 
treatment  practice.164 

Education  and  awareness  about  evidence-based 
practices,  however,  are  not  sufficient  to  ensure 
proper  implementation  of  those  practices;165 
additional  steps  are  necessary  to  translate 
evidence  into  practice.  Although  significant 
progress  has  been  made  in  the  past  decade  in 
disseminating  knowledge  about  evidence-based 
practices  and  improving  attitudes  toward  them, 
less  is  known  about  how  well  such  practices  are 
implemented  in  treatment  facilities  and 

166 

programs. 

One  study  found  that  treatment  programs  that 
are  most  likely  to  adopt  clinical  and  practice 
guidelines,  including  the  use  of  standardized 
assessment  tools,  are  those  that  offer  a  broad 
range  of  services-medical  services,  counseling, 
pharmaceutical  therapy  and  support  services- 


and  those  that  receive  funding  from  managed 
care  organizations. '  167 


1  Programs  with  managed  care  involvement  were  less 
likely  to  be  freestanding  facilities  and  more  likely  to 
be  associated  with  multi-service  hospital  or  medical- 
based  clinics.  They  also  were  more  likely  to  have 
staff  with  advanced  degrees  and  less  likely  to  have 
staff  in  recovery.  The  authors  of  this  study  speculate 
that  programs  with  managed  care  contracts  might  be 
likelier  than  those  without  such  contracts  to  be 
encouraged  to  have  standardized  practices. 


Evidence-based  practice  involves  the  use  of  current 
evidence  in  making  decisions  about  patient  care. 
Evidence-based  practices  aim  to  combine  the  best 
available  research  and  clinical  judgment  while  taking 
into  account  patient  characteristics  and  needs. 

-215- 


We  have  entered  the  world  of  showing  providers 
what  is  evidence  based.  Now  we  must  show 
providers  how  to  implement  it...  We  haven't 
effectively  brought  practical  research  results  to 
individual  providers... so  they  can  use  if. 168 

—William  H.  Janes 
Former  Director 
Florida  Office  of  Drug  Control 
Office  of  the  Governor 

Evidence  from  research  findings  is  not  generally 
accessible  and  understandable  to  providers; 
we  're  failing  miserably  at  that. 169 

-Joseph  M.  Amico,  MDiv 
President 

National  Association  of  Lesbian  and  Gay 
Addiction  Professionals 
(now  Vice  President,  and  association  now  called 
The  Association  of  Lesbian,  Gay,  Bisexual, 
Transgender  Addiction  Professionals 
and  Their  Allies) 

According  to  the  American  Psychological 
Association,  evidence-based  practice  is  the 
integration  of  the  best  available  research  and 
clinical  expertise  within  the  context  of  patient 
characteristics,  culture,  values  and  preferences. 
Today  we  have  a  few  places  trying  to  implement 
these  practices  but  with  major  limitations;  few 
ever  implement  the  practice  the  way  it  was 
researched.™ 

-Stephanie  Covington,  PhD,  LCSW 
Co-Director 
Center  for  Gender  and  Justice 
Institute  for  Relational  Development 
La  Jolla,  CA 


One  study  found  that  support  staff*— who  make 
up  24  percent  of  the  treatment  provider 
workforce  in  the  National  Institute  on  Drug 
Abuse's  (NIDA)  Clinical  Trial  Network  (CTN)T 
and  have  more  direct  patient  contact  than 
professional  counselors  and  medical  personnel- 
showed  little  enthusiasm  for  evidence-based 
practices;  they  also  were  more  likely  to  support 
intervention  techniques  that  employ 
confrontation  and  coercion-techniques  that 
contradict  evidence-based  practice.171  In 
contrast,  treatment  providers  affiliated  with  CTN 
who  advocated  for  the  use  of  new  evidence- 
based  practices  tended  to  be  more  highly 
educated.172 

A  study  of  counselors'  attitudes  toward 
evidence-based  psychosocial  and  pharmaceutical 
practices4  found  that  those  who  had  more 
specific  training  in  the  practices  and  those  who 
worked  in  treatment  centers  where  the  particular 
practices  were  used  routinely  tended  to  perceive 
evidence-based  practices  as  more  acceptable  for 
treating  addiction.173  Providers  with  higher 
educational  degrees  are  more  likely  to  be 
supportive  of  evidence-based  practices  than 
those  with  lower-level  degrees.174  In  contrast, 
providers  with  a  strong  12-step  orientation  to 
treatment  tend  to  perceive  evidence-based 
practices  as  less  acceptable.175 


For  many  recovering  paraprofessional 
counselors,  their  counseling  "trump  card"  is 
that  their  personal  experience  is  exemplary  of 

177 

how  recovery  works. 


Health  Professionals  do  not  Implement 
Evidence-Based  Addiction  Care  Practices^ 

Mainstream  medical  and  other  health 
professionals  do  not  adequately  address  risky 
substance  use  or  the  disease  of  addiction  in  their 
professional  practice,  in  part  because  they  are 
not  trained  to  do  so.**  176  and  in  part  because 
they  do  not  see  it  as  a  legitimate  element  of  their 
role  as  health  professionals. 

Education  and  training  alone,  however,  is 
insufficient  to  change  practice.  For  example, 
while  numerous  guidelines  have  been  produced 
and  disseminated  by  government  agencies,"  178 
professional  associations179  and  quality 
improvement  organizations  such  as  the  National 
Quality  Forum  (NQF)180  and  the  Agency  for 
Healthcare  Research  and  Quality  (AHRQ),181  to 
help  health  professionals  conduct  evidence- 
based  practices  related  to  risky  substance  use 
and  addiction,  physicians  and  other  health  care 
providers  commonly  fail  to  adhere  to  these 
clinical  practice  guidelines.182 

A  recognized  cadre  of  addiction  physician 
specialists  is  essential  to  help  educate  and  train 
other  physicians,  serve  as  equal  partners  in 
regular  medical  practice  and  provide  specialty 

183 

care. 

Efforts  also  must  be  made  to  translate  physician 
training  into  practice.  A  lack  of  time  and 
resources  make  it  difficult  for  physicians  to 
remain  up  to  date  with  the  latest  guidelines  and 
recommendations,  and  limited  reimbursement 
may  prevent  some  physicians  from  taking  the 
time  to  implement  practice  recommendations.184 


Support  staff  is  distinct  from  counselors,  managers 
or  supervisors  and  medical  personnel. 
1  CTN  is  a  partnership  between  NIDA  researchers 
and  community  treatment  providers  to  deliver  new 
evidence-based  treatments  to  a  broader  population  of 
patients  and  to  conduct  multi-site  clinical  trials  to 
determine  the  effectiveness  of  new  therapies  in 
diverse  settings. 

*  Including  the  use  of  buprenorphine,  methadone, 
naltrexone,  disulfiram,  motivational  enhancement 
therapy  and  voucher-based  motivational  incentives. 


§  See  Chapter  IX  for  a  detailed  discussion  of  the 
addiction-related  credentialing  requirements  for 
health  professionals. 

Most  of  the  research  related  to  the  training  of 
health  professionals  in  addiction-related  services 
focuses  on  tobacco  cessation  rather  than  interventions 
for  addiction  involving  alcohol  and  other  drugs. 
' '  e.g.,  The  Substance  Abuse  and  Mental  Health 
Services  Administration  (SAMHSA)  produces  the 
National  Registry  of  Evidence-Based  Programs  and 
Practices  (NREPP),  an  online  searchable  database  of 
evidence-based  interventions  for  mental  health  and 
addiction  prevention  and  treatment. 


-216- 


These  factors,  however,  are  not  sufficient  to 
justify  the  lack  of  medical  attention  to  a  disease 
affecting  1 6  percent  of  the  population. 

Physicians.  Poor  training  in  the  care  of  patients 
with  addiction  relates  to  low  confidence  among 
physicians  in  their  ability  or  competence  to  treat 
such  patients,  negative  attitudes  toward  patients 
with  addiction,  pessimism  about  the 
effectiveness  of  treatment  and  low  rates  of 
implementation  of  evidence-based  practices 
related  to  screening,  brief  interventions  and 
treatment.185 


Only  a  small  proportion  of  primary  care 
physicians  feel  "very  prepared"  to  detect 
particular  types  of  risky  use  (alcohol- 19.9 
percent;  illicit  drugs- 16.9  percent;  prescription 
drugs— 30.2  percent),  which  is  in  stark  contrast 
to  the  much  higher  percentages  of  physicians 
who  report  feeling  "very  prepared"  to  identify 
hypertension  (82.8  percent),  diabetes  (82.3 
percent)  and  depression  (44.1  percent).188  A 
state-based  2006  survey  of  primary  care 
physicians  found  that  the  vast  majority  (88 
percent)  screen  for  diabetes  in  adults  with  risk 
factors  such  as  obesity,  hypertension  and  a 
family  history  of  diabetes.189 

A  2004  survey  showed  that  less  than  one  third  of 
certain  medical  professionals— registered  nurses, 
dentists,  psychiatrists  and  emergency  medicine 
physicians— had  received  training  in  smoking 
cessation.190  Another  national  study  found  that 
only  half  of  psychiatry  residency  programs  offer 


training  in  tobacco  cessation,     even  though  a 
state -based  survey  found  that  94  percent  of 
psychiatry  residents  would  be  interested  in 
receiving  available  training.192  A  study  of 
fourth-year  medical  students  in  New  York  City 
found  that  the  majority  (85  percent)  did  not 
know  of  local  smoking  cessation  programs  to 
which  to  refer  patients.193  And  a  national  survey 
of  directors  and  assistant  directors  of  U.S. 
medical  school  obstetrics/gynecology  training 
programs  found  that  only  nine  percent  reported 
offering  students  at  least  1 5  minutes  of  time 
dedicated  to  improving  students'  tobacco 
cessation  skills  and  only  one-third  (32.9  percent) 
reported  that  their  programs  taught  students  both 
how  to  intervene  with  patients  who  smoke  and 
how  to  refer  them  for  follow-up.194 

Medical  curricula,  by  providing  insufficient 
information  about  recent  advances  in  the 
neurological  science  of  addiction,  perpetuate 
misconceptions  about  the  disease  of  addiction 
and  inhibit  the  acceptance  of  biological  models 
to  explain  the  disease.195 

Inadequate  training  with  regard  to  tobacco, 
alcohol  and  other  drug  use  also  derives  from 
limited  exposure  to  role  models  in  the  field  who 
have  knowledge  about  these  issues.196 
Curriculum  time  and  the  number  of  faculty  with 
expertise  in  addiction  education  pale  in 
comparison  to  curriculum  time  and  the  number 
of  faculty  with  expertise  in  education  for  health 
conditions  with  similar  prevalence  rates  as 
addiction,  such  as  cancer  and  heart  disease.197 


More  than  20  years  ago,  the  subspecialty  of 
addiction  psychiatry  officially  was 
established,199  yet  there  often  are  more  addiction 


Physicians  can  be  the  first  line  of  defense 
against  risky  substance  use  and  addiction,  but 
they  need  the  right  tools  and  resources}9,6 

-Nora  D.  Volkow,  MD 
Director 

National  Institute  on  Drug  Abuse 

Most  doctors  do  not  look  at  addiction  as  part  of 
their  job.  They  may  assess,  but  they  don 't 
intervene.1*1 

—Brian  Hurley 
Chair 

Physicians-in-training  Committee 
American  Society  of  Addiction  Medicine 


As  medical  students,  many  of  us  are  perplexed  by 
the  lack  of  a  formal  standard  of  care  regarding 
addiction.  The  sad  thing  is,  many  of  my  fellow 
students  and  I  feel  that  too  many  of  our  attending 
physicians  have  not  demonstrated  to  us  that  they 
believe  that  addiction  can  and  should  be 
addressed  and  that  attitude  affects  patient  care 
for  the  worse.™ 

— Kimberly  Fitzgerald 
Fourth-year  medical  student 


-217- 


psychiatry  residency  positions  available  than 
there  is  demand  for  them.  Although  a  survey  of 
psychiatry  residents  found  that  most  had  positive 
attitudes  towards  addiction  psychiatry,  few 
residents  believed  that  addiction  psychiatrists 
were  well  paid  and  less  than  half  (45  percent) 
believed  a  career  in  addiction  psychiatry  would 
be  satisfying.200 

The  lack  of  physician  training  in  addiction  and 
its  treatment  has  very  real  effects  on  patient 
care.  For  example,  overwhelming  evidence  has 
proven  that  smoking  cessation  interventions  are 
clinically  effective  and  cost  effective  and  that  a 
patient's  chances  of  quitting  smoking  are  nearly 
doubled  if  a  health  professional  advises  him  or 
her  to  quit.201  Yet  many  medical  schools  do  not 
require  clinical  training  in  smoking  cessation.202 


Other  Health  Professionals.  Doctoral-level 
clinical  psychologists  are  highly  trained  in 
psychosocial  therapies,  many  of  which  can  be 
applied  effectively  to  addressing  addiction  in  the 
significant  proportion  of  their  patient  population 
that  has  co-occurring  addiction  and  mental 
health  disorders.204  Yet  because  few 
psychologists  receive  adequate  training  in 
screening  and  intervention  for  risky  substance 
users  and  in  diagnosing,  treating  or  referring 
patients  with  addiction,  some  fail  to  identify 
risky  use  or  addiction  or  lack  confidence  in  their 


ability  to  provide  psychosocial  therapies.  For 
example,  one  study  found  that  17.1  percent  of 
clinical  psychologists  reported  that  a  barrier  to 
providing  smoking  cessation  counseling  was 
their  "lack  of  training  in  tobacco  cessation 
skills."  Other  reported  barriers  also  were  related 
to  a  lack  of  knowledge  about  the  disease:  that 
smoking  was  "not  the  client's  presenting 
problem"  (57. 1  percent);  that  smoking  cessation 
is  not  "a  priority  for  my  patients"  (28.7  percent); 
"it  may  interfere  with  therapy  goals"  (2 1 .2 
percent);  and  "smoking  patients  are  not 
interested  in  smoking  cessation  counseling" 
(19.8  percent).206 

Dental  professionals  also  receive  inadequate 
training  in  caring  for  patients  with  risky 
substance  use  and  addiction,207  despite 
significant  evidence  of  the  important  role  they 
can  play  in  screening,  intervention  and  referral 
to  treatment.208  There  are  no  national  standards 
for  tobacco  cessation  education  in  U.S.  dental 
schools  and  the  ability  to  provide  tobacco 
cessation  services  is  not  considered  a  clinical 
competency.209  Only  about  half  of  dental 
schools  and  dental  hygienist  programs*  have 
tobacco  cessation  clinical  activities  integrated  in 
their  student  clinics.210  This  is  despite  the  fact 
that  dental  professionals  are  highly  receptive  to 
receiving  substance-related  training211  and  that 
appropriate  training  early  in  a  clinician's  career 
increases  the  likelihood  that  such  interventions 
will  be  adopted  and  implemented  in  practice.212 

Nurses  constitute  the  largest  group  of  health 
care  professionals213  with  extensive  patient 
contact;  therefore,  they  are  ideally  situated  to 
perform  patient  education,  screening  and  brief 
intervention  services.214  Yet,  nurses  are  not 
adequately  prepared  to  perform  these  services, 
particularly  tobacco  cessation  for  which 
research  indicates  they  can  be  particularly 
effective.215  Barriers  to  the  implementation  of 
smoking  interventions  include  a  reported  lack  of 
motivation,  self-  efficacy,  institutional  support, 
time  and  training.216  Nursing  school  curricula 
have  little  tobacco  control  content;  there  is  a 
lack  of  tested  curricula,  nurse  educators  are  not 


Forty-seven  percent  of  dental  schools  and  55 
percent  of  dental  hygienist  programs. 


There  are  trained  clinicians  who  do  not  fully 
understand  the  nature  of  addiction. 

I  am  amazed  at  how  many  if  not  most  medical 
professionals  have  no  understanding  and  little 
education  on  the  subject. 

My  relapse  was  in  part  due  to  ignorance  in  the 
medical  profession  and  lack  of  medical 
addiction  understanding  during  a  life- 
threatening  illness. 

...I  escaped  the  clutches  of  doctors  and 
psychiatrists  with  their  prescription  pads  and 
rotten  advice  due  to  lack  of  understanding,  due 
to  lack  of  education.™ 

-Respondents  to  CAS  A  Columbia's 
Survey  of  Individuals  in  Long-Term  Recovery 


-218- 


trained  in  it  and  it  is  considered  to  be  a  low 
priority  in  already  overloaded  curricula.217 

Although  pharmacists  who  engage  in  tobacco 
cessation  interventions  are  effective  in  providing 
those  services,218  and  despite  the  important  role 
pharmacists  can  play  in  preventing  the  misuse  of 
controlled  prescription  drugs,219  most  are  not 
well  trained  to  perform  these  functions,  have 
little  confidence  to  do  so  and  believe  that  most 
patients  are  not  interested  in  having  them 

220 

intervene. 

A  study  in  California  found  that  the  majority  of 
pharmacists  (88  percent)  indicated  that  they 
would  be  interested  in  receiving  specialized 
training  in  tobacco  cessation  counseling  but 
fewer  than  eight  percent  had  received  any  formal 
training.221  A  study  of  pharmacists  in  Florida 
found  that  29.2  percent  reported  that  they 
received  no  addiction-related  education  in 
pharmacy  school  and  53.7  percent  reported  that 
they  had  never  referred  a  patient  to  addiction 

222 

treatment. 

Inadequate  Use  and  Development  of 
Pharmaceutical  Treatments  for  Addiction 

The  underutilization  of  pharmaceutical  therapies 
in  addiction  treatment  is  another  example  of  the 
disconnect  between  addiction  treatment  services 
and  medical  care.  Many  addiction  treatment 
providers  are  unable  to  prescribe  pharmaceutical 
therapies  and  medical  professionals  who  could 
prescribe  such  therapies  fail  to  address 
addiction.  A  related  problem  is  that  some 
medical  professionals  appear  to  have  a 
disproportionate  concern  about  the  safety  risks 
of  addiction  medications  relative  to  medications 
aimed  at  treating  other  medical  conditions.  For 
example,  although  side  effects  for  some 
addiction  medications  have  been  noted  and 
safety  concerns  raised-particularly  with  regard 
to  smoking  cessation  treatments,223  side  effects 
exist  for  many  medications  aimed  at  treating 
other  health  conditions  and  typically  are 
acknowledged  as  an  acceptable  risk  of  treatment. 

Even  when  utilizing  pharmaceutical  treatments, 
medical  professionals  often  fail  to  prescribe 
them  at  therapeutic  doses.  For  example, 


methadone,  which  is  used  in  treatment  for 
addiction  involving  opioids,  often  is  not 
prescribed  as  clinically  recommended, 
undermining  its  effectiveness.224  Specifically, 
although  it  is  well  understood  that  dosages 
between  60- 1 00  mg  per  day  promote  retention  in 
treatment  and  reduction  of  opioid  use,225  34 
percent  of  patients  are  given  doses  of  less  than 
60  mg  per  day  and  1 7  percent  are  given  doses  of 
less  than  40  mg  per  day.*  226  Treatment 
programs  more  likely  to  give  suboptimal  doses 
of  methadone  include  those  with  directors  who 
take  a  12-step  approach  to  addiction 

227 

treatment. 


Furthermore,  despite  the  potentially  vast  market 
for  pharmaceutical  treatments  for  addiction,  the 
pharmaceutical  industry  has  not  made 
substantial  investments  in  the  development  of 
new  and  effective  addiction  treatment 
medications.231  One  of  the  most  significant 
contributing  factors  to  the  increased  medical 
treatment  of  mental  health  disorders,  such  as 
depression  and  anxiety,  in  the  past  two  decades 
has  been  the  development  and  marketing  of 
pharmaceutical  treatments  for  these 
conditions.232  However  in  recent  years,  the 
pharmaceutical  industry  has  cut  back 
dramatically  on  investments  in  the  development 
of  new  pharmaceutical  therapies  for  these  and 
other  mental  health  conditions.233  The  large 
profits  that  pharmaceutical  companies  were  able 
to  accrue  from  medications  that  were  modified 


Although  initial  methadone  treatment  begins  at 
dosages  under  40  mg/day,  the  amount  is  increased 
gradually  until  cravings  disappear. 


The  Institute  of  Medicine  and  the  Office  of 
National  Drug  Control  Policy  (ONDCP)  have 
recommended  that  treatment  for  addiction 
involving  opioids  be  integrated  into  mainstream 
medical  practice  to  improve  availability  and 
quality.228  New  York  City  has  been  a  leader  in 
this  area  with  its  Methadone  Medical 
Maintenance  program  established  more  than  25 
years  ago,229  yet  only  56  percent  of  need  for 
methadone  treatment  in  New  York  City  was  met 
in  2009;230  inadequate  training  of  providers  may 
have  restricted  its  expansion  and  integration 
with  mainstream  medical  care. 


-219- 


versions  of  drugs  already  approved  by  the  Food 
and  Drug  Administration  meant  that  investments 
in  innovative  new  medications  were  limited. 
Coupled  with  the  rising  cost  of  research  and 
development,  the  fact  that  pharmaceutical 
companies  face  dramatic  losses  once  the  patents 
on  many  of  their  largest  money-making  drugs 
expire  makes  the  current  climate  for  the 
development  of  new  innovative  medications 
quite  unfavorable.234 

This  is  particularly  unfortunate  since  recent 
advances  in  addiction  science  have  highlighted 
specific  neurotransmitter  receptors  and 
transporters  that  underlie  addiction  and  that  are 
promising  targets  for  the  development  of 
medications  to  prevent  and  treat  addiction.235 

Aside  from  economic  concerns,  other  factors 
inhibiting  investments  in  new  pharmaceutical 
interventions  for  addiction  include  an 
underestimation  of  the  market  for  addiction 
treatment  medications  (i.e.,  the  size  of  the 
population  with  addiction),  the  belief  that  the 
majority  of  those  with  addiction  lack  health 
insurance  and  the  ability  to  pay  for  medications, 
and  the  long-standing  stigma  associated  with  the 
use  of  illegal  substances  and  the  disease  of 
addiction.236 


Translating  the  rapidly-evolving  science  of 
addiction  into  science-based  treatments  will 
require  dramatic  changes  in  incentives  for  the 
pharmaceutical  industry  to  invest  in  innovative 
medications,  increased  public  understanding  that 
addiction  is  a  treatable  disease,  and  increased 
involvement  of  the  health  care  system  in  its 
prevention  and  treatment. 


Inadequate  Quality  Assurance 

Addiction  treatment  providers  do  not  speak  with 
clarity  or  consistency  about  what  the  goals  of 
treatment  are,  what  counts  as  quality  treatment, 
how  performance  and  outcomes  should  be 
measured  and  what  practices  should  be 
implemented  to  improve  treatment  and  achieve 
measurable  outcomes.*  239  And  because 
addiction  treatment  for  the  most  part  is  not 
integrated  into  mainstream  health  care,  quality 
assurance  standards  and  efforts  to  improve  such 
standards  in  mainstream  medicine  largely  do  not 
apply  to  addiction  treatment.240  For  example, 
organizations  like  the  Council  on  Graduate 
Medical  Education  and  the  National  Advisory 
Council  on  Nurse  Education  and  Practice  are 
public-private  partnerships  with  Congressional 
mandates  to  provide  sustained  assessment  of  the 
needs  of  the  medical  and  nursing  fields.241 
However,  these  organizations  do  not  appear  to 
address  addiction  treatment  and  comparable 
organizations  for  addiction  treatment  do  not 
exist. 

Efforts  to  assure  quality  treatment  within  the 
mainstream  medical  system  for  patients  with 
addiction  are  not  typically  adhered  to.  For 
example,  as  far  back  as  1979,  the  American 
Medical  Association  (AMA)  adopted  as  policy 
the  AMA  Guidelines  for  Physician  Involvement 
in  the  Care  of  Sub  stance- Abusing  Patients, 
which  states  that  every  physician  must  assume 
clinical  responsibility  for  the  diagnosis  and 
referral  of  patients  with  addiction  and  explicates 
the  particular  competencies  needed  to  fulfill  that 
responsibility.  Other  similar  efforts  followed, 
with  a  national  conference  sponsored  by  the 
Office  of  National  Drug  Control  Policy,  the 
Leadership  Conference  on  Medical  Education  in 
Substance  Abuse,  in  2004.  Despite  these  and 
other  efforts  by  government  and  professional 
organizations  to  put  forth  guidelines  and 
principles  aimed  at  ensuring  proper  training  in 
risky  substance  use  and  addiction,  physicians 
continue  to  be  insufficiently  equipped  to  address 
the  needs  of  their  substance-involved  patients.242 


See  Chapter  IX. 


For  the  most  part,  SUDs  [substance  use 
disorders]  have  not  been  high  priority  targets 
for  the  pharmaceutical  industry.  Even  for 
smoking  cessation,  which  offers  a  huge 
potential  market,  investments  are  negligible 
compared  with  the  costs  associated  with 
developing  medications  to  treat  the 

237 

consequences  of  smoking. 

-Volkow  &  Skolnick,  2012 


-220- 


Efforts  to  assure  quality  treatment  for  addiction 
have  proven  highly  fallible,  with  many  barriers 
standing  in  the  way  of  adequate  performance 
and  outcome  measurement,  including  limited 
consensus  regarding  core  quality  standards  and 
measures,  inadequately  developed  measures  and 
improvement  mechanisms,  and  inadequate 
infrastructure  and  technical  capacity.243 

Further,  the  way  in  which  addiction  treatment  is 
evaluated  differs  considerably  from  the 
evaluation  of  the  effectiveness  of  treatment  for 
other  health  conditions  like  diabetes, 
hypertension  and  asthma.  Specifically, 
evaluations  of  the  effectiveness  of  treatment  of 
chronic  diseases  typically  are  conducted  while 
the  patient  continues  to  receive  treatment,  since 
the  treatment  is  considered  critical  to  managing 
the  disease.  In  the  case  of  chronic  addiction, 
however,  evaluations  of  treatment  effectiveness 
usually  are  conducted  after  the  treatment  has 
been  withdrawn.244  In  other  words,  we  use  an 
acute  care  model  to  evaluate  treatments  for  a 
chronic  condition. 

Furthermore,  because  treatment  facilities  in 
some  states  cannot  be  licensed  to  provide  both 
mental  health  and  addiction  treatment  services, 
the  mental  health  and  addiction  treatment 
systems  are  divided  further.  Given  the  large 
number  of  patients  who  suffer  from  co-occurring 
addiction  and  psychiatric  disorders,  the  inability 
to  treat  both  conditions  concurrently  within  the 
same  program  is  a  significant  barrier  to 
providing  quality  care;  it  reduces  the  diagnosis 
and  treatment  of  co-occurring  conditions, 
impedes  coordination  of  care,  and  increases  the 
number  of  transfers  which  disrupts  treatment.245 

Lack  of  Consensus  Regarding  the  Main  Goals 
of  Treatment.  The  primary  goals  of  medical 
care  are  the  prevention,  diagnosis  and  treatment 
of  illness,  injury  and  disease,  and  the  consequent 
relief  of  pain  and  suffering.246  The  picture  is  not 
as  clear  in  addiction  treatment:  there  is  little 
agreement  among  addiction  treatment  providers 
about  what  the  goals  of  treatment  are  or  should 
be  and  whether  successful  treatment  is  defined 
by  abstinence,  a  reduction  in  clinical  symptoms 
or  a  reduction  in  negative  health  and  social 
consequences.247  Goals  are  not  defined  as 


improving  health  and  function  or  disease 
stabilization  as  they  are  with  other  health 
conditions.  Such  inconsistency  in  goals  makes 
measuring  and  assessing  the  effectiveness  of 
treatment  very  difficult. 

CASA  Columbia's  survey  of  members  of  key 
treatment  provider  associations  found  that  the 
majority  (78.5  percent)  "strongly  agree"  that 
improvements  in  functioning  (e.g.,  employment, 
education,  parenting,  family  stability,  crime  and 
recidivism,  health,  happiness,  citizenship)  is  an 
important  goal  of  addiction  treatment;  about  half 
(52.5  percent)  "strongly  agree"  that  complete 
abstinence  is  an  important  goal;  44.0  percent 
"strongly  agree"  that  remission  of  clinical 
symptoms  is  an  important  goal;  and  43.8  percent 
"strongly  agree"  that  reduced  substance  use  is  an 
important  goal.  Nearly  half  (45.1  percent)  of 
respondents  "strongly  agree"  that  the  patient 
should  be  allowed  to  set  the  goal  that  is  right  for 
him  or  her.248 

Respondents  to  CASA  Columbia's  survey  of 
treatment  program  directors  and  staff  providers 
in  New  York  State  were  more  uniform  in  their 
support  of  complete  abstinence  as  the  main 
treatment  goal  for  someone  with  addiction 
involving  nicotine,  alcohol  or  other  drugs.249 
(Table  10.2) 


See  Appendix  F. 

-221- 


Table  10.2 

New  York  State  Addiction  Treatment 
Providers'  Opinions  of  the  Main  Goal  of 
Treatment,  by  Substance 


Program 
Directors 

Staff 
Providers 

Tobacco 

Complete  abstinence 

49.4 

48.2 

Reduced  use 

10.8 

21.3 

Fewer  negative  consequences 

4.8 

11.3 

Goal  set  by  patient 

41.0 

41.1 

Other  goal 

3.6 

6.4 

Alcohol 

Complete  abstinence 

61.4 

70.2 

Reduced  use 

3.6 

9.2 

Fewer  negative  consequences 

10.8 

9.2 

Goal  set  by  patient 

25.3 

22.0 

Other  goal 

2.4 

3.5 

Other  Drugs 

Complete  abstinence 

66.3 

65.2 

Reduced  use 

8.4 

9.2 

Fewer  negative  consequences 

13.3 

9.9 

Goal  set  by  patient 

30.1 

26.2 

Other  goal 

3.6 

5.7 

Source:  CASA  Columbia  Survey  of  New  York  State 
Addiction  Treatment  Providers,  2009.  


Inadequate  Performance  and  Outcome 
Measurement.  Government  and  private  funders 
and  insurance  companies  increasingly  are 
pressing  addiction  treatment  programs  to 
demonstrate  the  effectiveness  of  their  programs 
and  services.250  However,  most  programs  do  not 
measure  performance  or  treatment  outcomes  or 
have  reliable  evaluation  data  to  demonstrate  the 
efficacy  of  their  services.251  There  is  no 
national,  unified  body  that  sets  standards  for 
addiction  treatment.252 

CASA  Columbia's  survey  of  treatment  program 
directors  in  New  York  State  found  that,  when 
asked  about  the  three  main  ways  that  their 
program  evaluates  how  well  it  is  doing,  the  most 
common  response  offered  was  "program 
completion  rates"  (68.7  percent);  the  next  most 
common  response  was  "random  client 
feedback/testimonials"  (54.2  percent).  Neither 
of  these  measures  adequately  reflects  treatment 


quality  or  effectiveness.  Long-term  follow  up  of 
patients  is  not  typical,  as  only  34.9  percent  of 
program  directors  reported  following  patients  for 
more  than  six  months  after  treatment  exit  to 
assess  how  well  their  patients  were  faring.253 
Further  complicating  the  measurement  of 
outcomes  is  the  failure  to  understand  that 
addiction  in  many  cases  is  a  chronic  disease  that 
requires  management  over  time. 


The  effectiveness  of  addiction  treatment  is 
evaluated  based  on  perverted  measures  of 
success... you'd  never  judge  the  benefits  of  an 
antihypertensive  medication  AFTER  the 
medication  had  been  stopped.15* 

-Michael  M.  Miller,  MD 
Past  President 
American  Society  of  Addiction  Medicine 


Most  addiction  treatment  programs  lack 
resources  to  develop  and  implement  effective 
measurement  systems.255  Integrating  addiction 
treatment  into  mainstream  health  care,  however, 
would  permit  the  performance  and  outcome 
measures  and  standards  that  have  been  well 
established  for  the  treatment  of  other  health 
conditions  to  be  applied  to  addiction  treatment 
as  well. 

Inadequate  Insurance  Coverage 

In  spite  of  recent  expansions  in  coverage  for 
intervention  and  addiction  treatment  through 
health  care  parity  laws  and  the  Affordable  Care 
Act,  insurance  coverage  for  addiction  and 
related  services  remains  severely  limited 
compared  with  coverage  for  other  health 
conditions.*  256  This  lack  of  insurance  coverage 
for  effective— and  cost-effective— intervention 
and  addiction  treatment  services  provides  a 
further  barrier  to  increasing  the  attention  of 
health  care  professionals  to  this  disease.  The 
end  result  is  that  millions  of  Americans  are 
denied  treatment,  health  care  costs  continue  to 
rise  as  do  social  consequences  and  costs,  and 
taxpayers  foot  the  bill.257 


See  Chapter  VIII. 


-222- 


No  Overarching  Organizing  Body  for 
Addiction  Science  and  Treatment 

Unlike  other  major  health  conditions,  there  is  no 
highly  credible  and  unifying  organization, 
within  or  outside  of  the  National  Institutes  of 
Health  (NIH),  which  sets  standards  and 
advocates  for  addiction  prevention  and 
treatment,  including  all  manifestations  of 
addiction. 

A  key  mission  of  the  National  Cancer  Institute  is 
to  conduct  and  support  "research,  training, 
health  information  dissemination  and  other 
programs  with  respect  to  the  cause,  diagnosis, 
prevention  and  treatment  of  cancer, 
rehabilitation  from  cancer,  and  the  continuing 
care  of  cancer  patients  and  the  families  of  cancer 
patients."258  Likewise,  according  to  the 
American  Heart  Association's  description  of  its 
organization,  "we  fund  innovative  research,  fight 
for  stronger  public  health  policies  and  provide 
lifesaving  tools  and  information  to  prevent  and 
treat  these  diseases."259 

Although  there  are  federal  institutes  and 
organizations  dedicated  to  substance  use  and 
addiction,  including  the  National  Institute  on 
Drug  Abuse  (NIDA),  the  National  Institute  on 
Alcohol  Abuse  and  Alcoholism  (NIAAA)  and 
the  Substance  Abuse  and  Mental  Health 
Services  Administration  (SAMHSA)  as  well  as 
other  organizations  and  institutes  for  which 
substance  use  and  addiction  are  part  of  their 
focus,*  there  is  no  unified  body  that  promotes 
research,  public  awareness  and  prevention  and 
treatment  quality  for  the  disease  of  addiction. 
The  result  is  a  disjointed  array  of  programs  and 
efforts  that  often  have  quite  different 
perspectives  and  approaches  to  addressing  the 
issues  surrounding  substance  use  and  addiction, 
which  further  contributes  to  the  segmented  view 
of  addiction  as  multiple  substance-  and 
behavior-specific  problems,  rather  than  a  single 
disease  with  different  manifestations. 


Such  as  the  National  Cancer  Institute  (NCI), 
primarily  in  relation  to  smoking,  the  National 
Institute  of  Mental  Health  (NIMH)  and  the  Centers 
for  Disease  Control  and  Prevention  (CDC). 


A  recent  plan  by  the  NIH  would  combine  public 
health  initiatives  related  to  substance  use  and 
all  addiction-related  research  within  the  NIH 
into  a  new  institute  focused  on  substance  use 
and  addiction.260  This  proposal  is  controversial 
with  regard  to  how  the  merger  will  affect  the 
funding  and  research  portfolios  not  only  of 
NIDA  and  NIAAA  but  also  of  other  NIH 
institutes  with  interests  that  involve  substance 
use  and  addiction  (e.g.,  those  that  address 
cancer,  HIV,  prenatal  care,  birth  defects,  obesity, 
pain  control).261  Its  strength  is  a  clear  and  long- 
overdue  recognition  of  the  nature  of  the  disease 
of  addiction  and  the  importance  of  addressing  it 
in  a  unified  way. 

Efforts  to  Integrate  Substance  Use 
Prevention  and  Treatment  into 
Mainstream  Medicine 

Recent  efforts  aimed  at  improving  the 
prevention  of  risky  substance  use  and  the 
treatment  of  addiction  have  concentrated  on  the 
application  of  quality  improvement  and  quality 
assurance  measures  such  as  those  that  have 
gained  traction  in  mainstream  health  care 
practice: 

•  Developing,  disseminating  and  promoting 
evidence-based  practices;262 

•  Improving  the  treatment  provider  workforce 
through  enhanced  education  and  training;263 

•  Improving  performance  measures;264 

•  Shifting  evaluation  efforts  from  a  focus  on 
performance-based  measures  that  document 
the  process  of  service  delivery  to  a  focus  on 
patient  outcomes,  and  rewarding  those 
programs  that  demonstrate  positive  patient 
outcomes;265  and 

•  Using  electronic  health  records  and  other 
forms  of  health  information  technology  to 
track  and  monitor  patients  and  help  improve 
the  coordination  and  delivery  of  care.266 


-223- 


Many  of  these  efforts,  however,  have  been 
aimed  at  shoring  up  and  maintaining  a  separate 
system  of  addiction  treatment  outside  of 
mainstream  health  care  practice.  Although  these 
are  steps  in  the  right  direction,  the  research 
documented  in  this  report  demonstrates  clearly 
that  the  current  treatment  infrastructure  is 
riddled  with  barriers  to  closing  the  vast  gap 
between  research  evidence  and  practice.267  As 
such,  modifications  to  the  existing  system 
simply  will  not  suffice  to  make  significant, 
meaningful  and  lasting  improvements  in  how 
risky  substance  use  and  addiction  are  addressed 
in  the  United  States. 

What  is  required  is  an  integration  of  screening 
and  intervention  for  risky  substance  use  and 
treatment  and  management  of  addiction  into 
mainstream  health  care,  assuring  that  addiction 
treatment  is  managed  by  trained  medical 
professionals  and  supported  by  an  array  of 
highly-trained  clinical  mental  health 
professionals  and  other  providers  of  essential 
support  and  auxiliary  services.268  Such 
integrated  care  leads  to  improved  patient 
outcomes  and  significantly-reduced  medical 
costs.269 

Several  recent  developments  have  begun  to 
make  significant  strides  in  this  direction: 

•    Efforts  to  expand  insurance  coverage  for 
screening  and  brief  interventions  in  primary 
care  settings,  to  offer  equitable  coverage  for 
addiction  treatment  services  and  to  ensure 
accountability  by  establishing  quality 
benchmarks  in  patient  care  as  a  condition  for 


coverage. 


270 


Efforts  by  professional  societies  and 
associations  to  professionalize  addiction 
treatment,  have  the  medical  field  respond  to 
risky  substance  use  as  a  public  health 
problem  and  addiction  as  a  medical 
condition,  and  integrate  care  for  risky 
substance  use  and  addiction  into  medical 
practice.  Notable  examples  include: 

>   The  American  Society  of  Addiction 
Medicine  (ASAM)  which  is  seeking  to 
improve  the  quality  of  care  for  risky 


substance  use  and  addiction  by: 
educating  physicians  and  other  health 
professionals  about  these  issues; 
supporting  research  and  prevention 
efforts;  advocating  for  state  and  federal 
policies  that  would  expand  access  to 
treatment;  and  working  to  establish 
addiction  medicine  as  a  recognized 
medical  specialty.271 

>  The  American  Board  of  Addiction 
Medicine  (ABAM),  which  was  founded 
in  2007  with  the  encouragement  and 
assistance  of  ASAM,  is  working  toward 
the  goal  of  establishing  addiction 
medicine  as  a  medical  specialty 
recognized  by  the  American  Board  of 
Medical  Specialties  (ABMS).  ABAM's 
sister  organization,  the  ABAM 
Foundation,  began  accrediting  one-  or 
two-year  fellowship  training  programs- 
"secondary  residencies"— in  addiction 
medicine  open  to  physicians  completing 
training  in  any  field  certified  by  the 
ABMS  member  boards.  Such 
programs  have  the  ability  to  train  the 
physician  experts  needed  to  meet  the 
demand  within  health  care  teams  at  all 
locations  where  regular  medical  care  is 
received-from  hospitals  to  community 
clinics.  The  ABAM  Foundation  also  is 
working  toward  having  its  fellowship 
training  programs  accredited  by  the 
Accreditation  Counsel  for  Graduate 
Medical  Education  (ACGME).272 
NIAAA  and  NIDA  recently  awarded 
grants  to  SUNY  Buffalo  and  to  Boston 
University  Medical  Center  to  help 
support  this  effort.273 

>  The  American  Society  of  Health- 
Systems  Pharmacists,  a  member  of  the 
National  Pharmacy  Partnership  for 
Tobacco  Cessation,  which  has  created  a 
resource  center  to  provide  pharmacists 
with  tobacco  cessation  information  and 
tools  to  help  patients  stop  smoking.274 


The  ABAM  Foundation  to  date  has  accredited  10 
addiction  medicine  training  programs  across  the 
country,  with  more  programs  under  development. 


-224- 


•    Efforts  by  government  agencies  to  promote 
physician  education  and  training  in 
addiction  science  and  addiction  treatment 
and  upgrade  health  care  professionals'  skills 
through  the  development  and  dissemination 
of  screening  tools  and  evidence-based 
clinical  guidelines.275  Notable  examples 
include: 

>  The  National  Institute  on  Drug  Abuse's 
NIDAMED,  a  physician  outreach 
initiative  aimed  at  encouraging  doctors 
to  screen  patients  for  risky  substance 
use,  including  tobacco,  alcohol  and 
other  drugs.  NIDAMED  offers  free 
screening  tools  and  prevention  and 
treatment  research  and  information  that 
physicians  can  share  with  their  patients. 
It  also  offers  curriculum  resources  to 
provide  scientifically  accurate 
information  to  medical  students, 
residents  and  faculty  about  substance 
use,  addiction  and  its  consequences.276 

>  The  Substance  Abuse  and  Mental  Health 
Services  Administration's  SBIRT* 
Medical  Residency  Program,  which 
seeks  to  develop  and  implement  training 
programs  for  medical  residents  in 
evidence-based  screening,  brief 
intervention,  brief  treatment  and  referral 
to  specialty  treatment  for  risky 
substance  use  and  addiction  involving 
alcohol  and  other  drugs,  and  to  promote 
more  broadly  the  adoption  of  these 
practices  in  the  medical  field.277 

>  The  Health  Resources  and  Services 
Administration's  Project 
MAINSTREAM,  which  provides 
resources  for  educating  a  broad  range  of 
health  care  professionals '  in  screening, 
brief  intervention,  referral  to  treatment, 


Screening,  Brief  Intervention,  Referral  and 
Treatment. 

f  Including  audiologists,  dentists,  dieticians,  nurse 
midwives,  nurse  practitioners,  nurses,  occupational 
therapists,  pharmacists,  physical  therapists,  physician 
assistants,  physicians,  psychologists,  public  health 
professionals,  social  workers  and  speech  pathologists. 


identifying  and  assisting  children  of 
parents  with  addiction  and  helping 
communities  implement  effective 
prevention  programs  related  to  addiction 
involving  all  substances.278 

•  Smaller-scale  efforts  to  provide  brief 
training  to  health  professionals1'  in  addiction 
science  in  order  to  improve  the  attitudes, 
proficiency  and  practices  of  all  health 
professionals279-not  just  those  who  choose 
to  specialize  in  addiction  medicine  or 
addiction  psychiatry.  Such  brief  trainings 
have  proven  effective  in  improving  health 
professionals'  knowledge,  attitudes, 
confidence,  motivation  and  practices  with 
regard  to  providing  smoking  cessation 
services;280  conducting  screening  and  brief 
interventions  for  risky  alcohol  use  in 
emergency  departments281  and  for  risky 
alcohol  and  other  drug  use  in  primary  care 
facilities;282  and  for  prescribing 
pharmaceutical  medications  such  as 
methadone  and  buprenorphine  for  patients 
with  addiction  involving  opioids.283 

•  The  emergence  of  Patient-Centered  Medical 
Homes284-in  which  a  team  of  health 
professionals  provides  comprehensive  and 
continuous  medical  care-is  proving  to  be  a 
strong  model  for  addiction  treatment  to  be 
integrated  into  the  primary  medical  care 
system.285  Recent  research  within  the 
Medicaid  and  Veterans  Health 
Administration  systems  demonstrates  the 
success  of  this  approach286  and  the  potential 
to  incorporate  addiction  care  into  this 
integrated  system. 

•  Efforts  by  quality  assurance  organizations  to 
encourage  services  that  address  risky 
substance  use  and  addiction  within 
mainstream  health  care.  For  example,  in 
2012,  the  Joint  Commission  announced  new, 
voluntary  measures  for  hospitals  that  choose 
to  provide  screening,  brief  intervention  and 
referral  to  treatment  for  tobacco,  alcohol  and 


1  Including  but  not  limited  to  physicians,  physician 
assistants,  nurses,  nurse  practitioners,  dental 
professionals,  pharmacists,  social  workers. 


-225- 


other  drug  use.  The  performance 
measurement  sets  related  to  alcohol  and 
other  drugs  include  screening,  brief 
interventions,  treatment,  discharge  planning 
and  follow  up.287  The  specifications  for  the 
tobacco  cessation  performance  measures 
include  screening  all  patients  to  identify 
tobacco  users,  providing  or  offering 
evidence-based  counseling  and  medications 
for  smokers  during  hospitalization  and  upon 
discharge,  and  assessing  tobacco  use  30 
days  post-discharge.288  Hospitals  are 
required  to  choose  four  out  of  14  possible 
core  performance  measurement  sets,  with  no 
requirements  about  which  sets  must  be 
chosen.289  For  each  core  performance 
measurement  set  that  the  hospital  chooses, 
the  hospital  is  held  accountable  for 
collecting  data  and  measuring  performance 
related  to  the  activities  associated  with  the 
set.  However,  other  sets  of  measures  that 
hospitals  may  choose  to  be  held  accountable 
for  include  those  that  they  already  perform 
routinely,  limiting  the  reach  of  this 
promising  development  which  would  require 
more  effort  and  resources  than  most  other 

290 

measurement  sets. 


Our  perspective  is  that,  although  tactically 
impressive,  the  [Joint  Commission's] 
measure  set  [regarding  tobacco  screening  and 
cessation  services]  is  strategically  flawed 
because  its  adoption  is  optional.291 

-Fiore,  M.C.,  Goplerud,  E.,  & 
Schroeder,  S.  A.  (2012) 

If  the  Joint  Commission  would  require 
hospitals  to  report  their  outcomes  on  SBIRT, 
it  could  do  more  to  medicalize  how  we  deal 
with  risky  substance  use  than  all  the  urging 
and  pleading  we 've  undertaken  for  the  past 
25  to  30  years.292 

-Larry  M.  Gentilello,  MD 
Trauma  Services 
Kaiser  Permanente  Hospital 
Sacramento,  CA 


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Chapter  XI 

Recommendations  and  Next  Steps 


As  this  report  has  documented,  addiction  is  a 
complex  brain  disease  and  the  risky  use  of 
addictive  substances  is  a  significant  public 
health  problem.  Together  they  result  in  untold 
human  suffering  and  cost  taxpayers  billions  of 
dollars  each  year.  Effective,  evidence-based 
interventions  and  treatment  options  exist  that 
can  and  should  be  delivered  through  the  health 
care  system.  A  substantial  body  of  research 
demonstrates  that  providing  effective 
prevention,  intervention,  treatment  and  disease 
management  services  yields  improvements  in 
health  and  considerable  reductions  in  costs  to 
government  and  taxpayers;  research  also 
suggests  that  providing  these  services  does  not 
result  in  significant  increases  in  insurance  costs. 
In  the  face  of  these  facts,  it  is  unethical, 
inhumane  and  cost  prohibitive  to  continue  to 
deny  effective  care  and  treatment  for  the  40.3 
million  Americans  with  this  disease  or  to  fail  to 
screen  and  intervene  with  the  80.4  million  who 
engage  in  risky  use  of  addictive  substances. 

No  one  group  or  sector  alone  can  realize  the 
changes  required  in  health  care  practice, 
government  regulation  and  spending,  insurance 
coverage,  and  public  understanding  to  bring 
addiction  prevention  and  treatment  and 
reductions  in  risky  substance  use  in  line  with  the 
standard  of  care  for  other  public  health  and 
medical  conditions.  Concerted  action  is  required 
on  the  part  of  physicians  and  other  medical  and 
health  professionals,  policy  makers,  insurers  and 
the  general  public. 

This  is  not  an  unprecedented  challenge.  There 
have  been  many  examples  where  health  care 
practice  has  lagged  behind  the  science.  Only 
recently,  depression  was  considered  a  character 
flaw  before  the  brain  science  was  understood 
and  HIV/AIDS  was  considered  a  moral  scourge 
before  it  was  seen  as  a  virus  that  can  be 
prevented,  treated,  managed  and  perhaps  cured. 
Likewise,  addiction  has  been  seen  for  too  long 


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as  a  character  flaw  and  a  moral  failing  rather 
than  a  preventable  and  treatable  disease. 

It  is  past  time  for  health  care  practice  to  catch  up 
with  the  science.  Efforts  already  underway  to 
close  this  gap  must  be  expanded  and  accelerated. 
Toward  this  end,  CASA  Columbia  makes  the 
following  recommendations: 

Reform  Health  Care  Practice 

Incorporate  Screening  and  Intervention  for 
Risky  Substance  Use,  and  Diagnosis, 
Treatment  and  Disease  Management  for 
Addiction  into  Routine  Medical  Practice 

As  essential  components  of  routine  medical  care 
practice,  all  physicians  and  other  medical 
professionals  should  provide  their  patients  with: 

•  Routine  screening  for  all  forms 

of  risky  substance  use—including  tobacco, 
alcohol,  illicit  drugs  and  controlled 
prescription  drugs-at  initial  visit  to  a 
primary  care  or  specialty  care  physician  and 
routinely  thereafter,  and  upon  entry  into  a 
hospital,  emergency  department,  trauma 
center  or  clinic; 

•  Brief  interventions  as  needed; 

•  Comprehensive  assessment  to  determine 
disease  stage  and  severity  as  well  as  the 
presence  of  co-occurring  health  conditions 
and  special  population  needs; 

•  Patient  stabilization  (e.g.,  detoxification), 
when  necessary,  as  a  precursor  to  treatment; 

•  Development  of  a  tailored  treatment  plan 
that  includes: 

>  Acute  treatment  via  evidence-based 
psychosocial  and/or  pharmaceutical 
interventions; 

>  Chronic  disease  management,  as 
needed; 


>  Connection  to  support  and  auxiliary 
services-including  legal,  educational, 
employment,  housing  and  family 
supports,  nutrition  and  exercise 
counseling,  and  mutual  support 
programs;  and 

>  Referral  to  physicians  trained  in 
addiction  medicine  or  addiction 
psychiatry  for  specialty  care  as  needed. 

Evidence-based  screening  can  be  conducted  by  a 
broad-range  of  licensed  providers  with  general 
training  in  addiction  and  specific  training  in  how 
to  conduct  such  screens  and  what  to  do  with 
patients  who  screen  positive.  Brief  interventions 
can  be  provided  by  health  professionals- 
licensed  graduate-level  medical  or  mental  health 
clinicians-trained  in  addiction  care. 

Treatment  and  disease  management  services  can 
be  provided  through  a  multi-disciplinary  team  of 
appropriately  trained  and  credentialed  health 
professionals  managed  by  a  physician: 

•  Comprehensive  assessment,  diagnosis, 
stabilization,  acute  treatment  and  disease 
management  must  be  performed  or  managed 
by  physicians  in  collaboration  with  a  team 
of  licensed  graduate- level  medical  or  mental 
health  clinicians  trained  in  addiction  care; 

•  Case  management  can  be  provided  by 
licensed  physician  assistants,  nurses  and 
nurse  practitioners  and  mental  health 
clinicians  trained  in  addiction  care; 

•  Auxiliary  services  can  be  provided  by  a 
range  of  professional  and  paraprofessional 
personnel  working  within  the  treatment  and 
disease  management  plan; 

•  Peer  support,  often  an  important  component 
of  the  larger  treatment  plan,  can  be  provided 
by  those  who  have  learned  to  manage  the 
disease. 


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All  Medical  Schools  and  Residency 
Training  Programs  Should  Educate  and 
Train  Physicians  to  Address  Risky 
Substance  Use  and  Addiction 

All  physicians  should  be  educated  and  trained  in 
the  origins  of  risky  substance  use  and  addiction; 
prevention,  intervention,  treatment  and 
management  options;  co-occurring  conditions; 
and  special  population  and  specialty-care  needs, 
including: 

•  What  constitutes  risky  substance  use,  the 
harms  of  such  use  to  health  and  safety  and 
the  importance  of  reducing  risky  use; 

•  How  to  screen  for  risky  substance  use  and 
conduct  brief  interventions  when  indicated; 

•  The  causes  and  correlates  of  addiction; 

•  How  to  diagnose  addiction;  evaluate  disease 
stage,  severity,  co-occurring  disorders  and 
needs  of  special  populations;  and  develop  a 
treatment  and  disease  management  plan 
including  appropriate  support  services; 

•  How  to  collaborate  with  and  manage  a 
multidisciplinary  team  of  providers; 

•  How  to  provide  or  supervise  psychosocial 
and  pharmaceutical  treatments  for  addiction 
and  disease  management; 

•  How  to  arrange  for  and  connect  patients 
with  auxiliary  support  services;  and 

•  How  to  determine  the  need  for  specialty  care 
and  connect  patients  with  such  care. 

These  core  clinical  competencies  should  be 
required  components  of  all  medical  school 
curricula,  medical  residency  training  programs, 
medical  licensing  exams,  board  certification 
exams  and  continuing  medical  education  (CME) 
requirements,  including  maintenance  of 
certification  programs. 


Require  Non-Physician  Health 
Professionals  to  be  Educated  and  Trained 
to  Address  Risky  Substance  Use  and 
Addiction 

Develop  core  clinical  competencies  in 
addressing  risky  substance  use  and  preventing 
and  treating  addiction  for  each  type  of  non- 
physician  health  professional  including 
physician  assistants,  nurses  and  nurse 
practitioners,  dentists,  pharmacists  and  graduate- 
level  clinical  mental  health  professionals 
(psychologists,  social  workers,  counselors). 
These  competencies  should  include: 

•  What  constitutes  risky  substance  use,  the 
harms  of  such  use  to  health  and  safety  and 
the  importance  of  reducing  risky  use; 

•  How  to  screen  for  risky  substance  use  and 
conduct  brief  interventions  when  indicated; 

•  The  causes  and  correlates  of  addiction; 

•  Available  psychosocial  and  pharmaceutical 
treatments  for  addiction  and  disease 
management; 

•  How  to  arrange  for  and  connect  patients 
with  auxiliary  support  services;  and 

•  How  to  determine  the  need  for  specialty  care 
and  connect  patients  with  such  care. 

Assure  that  these  core  clinical  competencies  and 
specialized  training  are  required  components  of 
all  professional  health  care  program  curricula, 
graduate  fellowship  training  programs, 
professional  licensing  exams  and  continuing 
education  (CE)  requirements. 

For  non-physician  health  professionals  involved 
in  the  provision  of  addiction  care,  core 
competencies  also  should  include  how  to  work 
in  concert  with  a  patient's  physician  and  other 
health  care  providers  to  screen  for  risky 
substance  use;  provide  brief  interventions; 
diagnose  addiction;  evaluate  disease  stage, 
severity  and  co-occurring  disorders;  and  develop 


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a  treatment  plan,  including  appropriate  support 
services. 

Require  all  non-physician  health  professionals 
providing  psychosocial  addiction  treatment 
services  to  have  graduate-level  clinical  training 
in  delivering  these  services. 

Require  that  all  pharmaceutical  treatments  for 
addiction  be  provided  only  by  a  physician  or  in 
accordance  with  a  treatment  plan  managed  by  a 
physician. 

Develop  Improved  Screening  and 
Assessment  Instruments 

Screening  instruments  should  be  adjusted  or 
developed  to  coincide  with  appropriate 
definitions  of  risky  substance  use,  and 
assessment  instruments  should  be  adjusted  or 
developed  to  mirror  diagnostic  criteria  for 
addiction.  Both  screening  and  assessment 
instruments  should  address  all  types  of  addictive 
substances. 

Establish  National  Accreditation  Standards 
for  All  Addiction  Treatment  Facilities  and 
Programs  that  Reflect  Evidence-Based 
Care 

As  a  condition  of  accreditation,  accrediting 
organizations  should  stipulate  requirements  for 
all  facilities  and  programs  providing  addiction 
treatment  with  regard  to  professional  staffing, 
intervention  and  treatment  services  and  quality 
assurance: 

•    Professional  Staffing.  All  facilities  and 
programs  providing  addiction  treatment 
should  be  required  to  have  a  full-time 
certified  addiction  physician  specialist  on 
staff  to  serve  as  medical  director,  oversee 
patient  care  and  be  responsible  for  all 
treatment  services.  All  individual  providers 
of  patient  care  in  these  facilities  and 
programs  should  be  required  to  be  licensed 
in  their  field  of  practice  and  demonstrate 
mastery  of  the  core  clinical  competencies. 
Professionals  who  are  in  the  process  of 


becoming  licensed  must  be  supervised  at  all 
tim